SUPPLEMENT ARTICLES
Expert Panel on Integrated Guidelines for
Cardiovascular Health and Risk Reduction in Children
and Adolescents: Summary Report
EXPERT PANEL ON INTEGRATED GUIDELINES FOR
CARDIOVASCULAR HEALTH AND RISK REDUCTION IN
CHILDREN AND ADOLESCENTS
ABBREVIATIONS
CVD—cardiovascular disease
NHLBI—National Heart, Lung, and Blood Institute
RCT—randomized controlled trial
PDAY—Pathobiological Determinants of Atherosclerosis in
Youth
BP—blood pressure
HDL—high-density lipoprotein
DM—diabetes mellitus
CIMT—carotid intima-media thickness
LDL—low-density lipoprotein
T1DM—type 1 diabetes mellitus
T2DM—type 2 diabetes mellitus
TC—total cholesterol
AAP—American Academy of Pediatrics
DGA—Dietary Guidelines for Americans
NCEP—National Cholesterol Education Program
DASH—Dietary Approaches to Stop Hypertension
CHILD—Cardiovascular Health Integrated Lifestyle Die
FLP—fasting lipid profile
CDC—Centers for Disease Control and Prevention
AMA—American Medical Association
MCHB—Maternal and Child Health Bureau
FDA—Food and Drug Administration
AHA—American Heart Association
www.pediatrics.org/cgi/doi/10.1542/peds.2009-2107C
doi:10.1542/peds.2009-2107C
Accepted for publication Sep 8, 2011
Address correspondence to Janet M. de Jesus, MS, RD, 31
Center Dr, Building 31, Room 4A17, MSC 2480, Bethesda, MD
20892. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2011 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: Dr Daniels has served as a consultant
for Abbott Laboratories, Merck, and Schering-Plough and has
received funding/grant support for research from the National
Institutes of Health (NIH); Dr Gidding has served as a consultant
for Merck and Schering-Plough and has received funding/grant
support for research from GlaxoSmithKline; Dr Gillman has
given invited talks for Nestle Nutrition Institute and Danone and
has received funding/grant support for research from Mead
Johnson, Sanofi-Aventis, and the NIH; Dr Gottesman has served
on the Health Advisory Board, Child Development Council of
Franklin County, was a consultant to Early Head Start for Region
5B, has written for iVillage and taught classes through Garrison
(Continued on last page)
1. INTRODUCTION
Atherosclerotic cardiovascular disease (CVD) remains the leading cause
of death in North Americans, but manifest disease in childhood and adolescence is rare. By contrast, risk factors and risk behaviors that accelerate the development of atherosclerosis begin in childhood, and there is
increasing evidence that risk reduction delays progression toward clinical
disease. In response, the former director of the National Heart, Lung, and
Blood Institute (NHLBI), Dr Elizabeth Nabel, initiated development of cardiovascular health guidelines for pediatric care providers based on a formal
evidence review of the science with an integrated format addressing all
the major cardiovascular risk factors simultaneously. An expert panel was
appointed to develop the guidelines in the fall of 2006.
The goal of the expert panel was to develop comprehensive evidence-based
guidelines that address the known risk factors for CVD (Table 1-1) to assist
all primary pediatric care providers in both the promotion of cardiovascular health and the identification and management of specific risk
factors from infancy into young adult life. An innovative approach was
needed, because a focus on cardiovascular risk reduction in children
and adolescents addresses a disease process (atherosclerosis) in
which the clinical end point of manifest CVD is remote. The recommendations, therefore, need to address 2 different goals: the prevention of
risk-factor development (primordial prevention) and the prevention of
future CVD by effective management of identified risk factors (primary
prevention).
The evidence review also required an innovative approach. Most systematic evidence reviews include 1 or, at most, a small number of finite
questions that address the impact of specific interventions on specific
health outcomes, and a rigorous literature review often results in only
a handful of in-scope articles for inclusion. Typically, evidence is limited
to randomized controlled trials (RCTs), systematic reviews, and metaanalyses published over a defined time period. There is a defined format for abstracting studies, grading the evidence, and presenting of
results. The results of the review lead to the conclusions, independent
of interpretation.
By contrast, given the scope of the charge to the expert panel, this
evidence review needed to address a broad array of questions concerning the development, progression, and management of multiple
risk factors extending from birth through 21 years of age, including
studies with follow-up into later adult life. The time frame extended
back to 1985, ⬃5 years before the review for the last NHLBI guideline
addressing lipids in children published in 1992.1 This evidence is
largely available in the form of epidemiologic observational studies
PEDIATRICS Volume 128, Supplement 5, December 2011
S213
TABLE 1-1 Evaluated Risk Factors
TABLE 1-2 Evidence Grading System: Quality Grades
Family history
Age
Gender
Nutrition/diet
Physical inactivity
Tobacco exposure
BP
Lipid levels
Overweight/obesity
Diabetes mellitus
Predisposing conditions
Metabolic syndrome
Inflammatory markers
Perinatal factors
Grade
Evidence
A
Well-designed RCTs or diagnostic studies performed on a population similar to the guideline’s
target population
RCTs or diagnostic studies with minor limitations; genetic natural history studies;
overwhelmingly consistent evidence from observational studies
Observational studies (case-control and cohort design)
Expert opinion, case reports, or reasoning from first principles (bench research or animal
studies)
(rather than RCTs) that, therefore,
must be included in the review. In addition, the review required critical appraisal of the body of evidence that addresses the impact of managing risk
factors in childhood on the development and progression of atherosclerosis. Because of known gaps in the evidence base relating risk factors and
risk reduction in childhood to clinical
events in adult life, the review must include the available evidence that justifies evaluation and treatment of risk
factors in childhood. The process of
identifying, assembling, and organizing the evidence was extensive, the review process was complex, and the
conclusions could only be developed
by interpretation of the body of evidence. Even with inclusion of every relevant study from the evidence review,
there were important areas in which
the evidence was inadequate. When
this occurred, recommendations were
made on the basis of a consensus of
the expert panel. The schema used in
grading the evidence appears in Tables 1-2 and 1-3; expert consensus
opinions are identified as grade D.
The NHLBI expert panel integrated
guidelines for cardiovascular health
and risk reduction in children and adolescents contain recommendations
based on the evidence review and are
directed toward all primary pediatric
care providers: pediatricians, family
practitioners, nurses and nurse prac-
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EXPERT PANEL
B
C
D
Adapted from American Academy of Pediatrics, Steering Committee on Quality Improvement and Management. Pediatrics.
2004;114(3):874 – 877.
titioners, physician assistants, and
registered dietitians. The full report
contains complete background information on the state of the science,
methodology of the evidence review
and the guideline-development process, summaries of the evidence reviews according to risk factor, discussion of the expert panel’s rationale for
recommendations, and ⬎1000 citations from the published literature and
is available at www.nhlbi.nih.gov/
guidelines/cvd_ped/index.htm.
The
complete evidence tables will be available as a direct link from that site. This
summary report presents the expert
panel’s recommendations for patient
care relative to cardiovascular health
and risk-factor detection and management with only the references cited in
the text provided. It begins with a stateof-the-science synopsis of the evidence, which indicates that atherosclerosis begins in childhood, and the
extent of atherosclerosis is linked directly to the presence and intensity of
known risk factors. This is followed by
a cardiovascular health schedule (Section 3), which summarizes the expert
panel’s age-based recommendations
according to risk factor in a 1-page periodic table. Risk factor specific sections follow, with the graded conclusions of the evidence review, normative
tables, and age-specific recommendations. These recommendations are often
accompanied by supportive actions,
which represent expert consensus suggestions from the panel provided to support implementation of the recommen-
dations. The summary report will be
released simultaneously with online
availability of the full report with references for each section and the evidence
tables at www.nhlbi.nih.gov/guidelines/
cvd_ped/index.htm.
It is the hope of the NHLBI and the expert
panel that these recommendations will be
useful for all those who provide cardiovascular health care to children.
2. STATE OF THE SCIENCE:
CARDIOVASCULAR RISK FACTORS
AND THE DEVELOPMENT OF
ATHEROSCLEROSIS IN CHILDHOOD
Atherosclerosis begins in youth, and this
process, from its earliest phases, is related to the presence and intensity of the
known cardiovascular risk factors
shown in Table 1-1. Clinical events such
as myocardial infarction, stroke, peripheral arterial disease, and ruptured aortic aneurysm are the culmination of the lifelong vascular process
of atherosclerosis. Pathologically, the
process begins with the accumulation
of abnormal lipids in the vascular intima, a reversible stage, progresses to
an advanced stage in which a core of
extracellular lipid is covered by a fibromuscular cap, and culminates in
thrombosis, vascular rupture, or acute
ischemic syndromes.
Evidence Linking Risk Factors in
Childhood to Atherosclerosis at
Autopsy
Atherosclerosis at a young age was
first identified in Korean and Vietnam
SUPPLEMENT ARTICLES
TABLE 1-3 Evidence Grading System: Strength of Recommendations
Statement Type
Definition
Implication
Strong recommendation
The expert panel believes that the benefits of the recommended approach
clearly exceed the harms and that the quality of the supporting
evidence is excellent (grade A or B). In some clearly defined
circumstances, strong recommendations may be made on the basis of
lesser evidence when high-quality evidence is impossible to obtain and
the anticipated benefits clearly outweigh the harms.
Clinicians should follow a strong recommendation
unless a clear and compelling rationale for an
alternative approach is present.
Recommendation
The expert panel feels that the benefits exceed the harms but that the
quality of the evidence is not as strong (grade B or C). In some clearly
defined circumstances, recommendations may be made on the basis of
lesser evidence when high-quality evidence is impossible to obtain and
when the anticipated benefits clearly outweigh the harms.
Clinicians should generally follow a
recommendation but remain alert to new
information and sensitive to patient
preferences.
Optional
Either the quality of the evidence that exists is suspect (grade D) or wellperformed studies (grade A, B, or C) have found little clear advantage
to one approach versus another.
Clinicians should be flexible in their decisionmaking regarding appropriate practice,
although they may set boundaries on
alternatives; patient and family preference
should have a substantial influencing role.
No recommendation
There is both a lack of pertinent evidence (grade D) and an unclear
balance between benefits and harms.
Clinicians should not be constrained in their
decision-making and be alert to new published
evidence that clarifies the balance of benefit
versus harm; patient and family preference
should have a substantial influencing role.
Adapted from American Academy of Pediatrics, Steering Committee on Quality Improvement and Management. Pediatrics. 2004;114(3):874 – 877.
War casualties. Two major contemporary studies, the Pathobiological Determinants of Atherosclerosis in Youth
(PDAY) study2 and the Bogalusa Heart
Study,3 subsequently evaluated the extent of atherosclerosis in children, adolescents, and young adults who died
accidentally. The Bogalusa study3 measured cardiovascular risk factors
(lipid levels, blood pressure [BP], BMI,
and tobacco use) as part of a comprehensive school-based epidemiologic
study in a biracial community. These
results were related to atherosclerosis measured at autopsy after accidental death. Strong correlations were
shown between the presence and intensity of risk factors and the extent
and severity of atherosclerosis. In the
PDAY study,2 risk factors and surrogate measures of risk factors were
measured after death in 15- to 34-year
olds who died accidentally of external
causes. Strong relationships were
found between atherosclerotic severity and extent, and age, non–
high-density lipoprotein (HDL) cholesterol, HDL cholesterol, hypertension
(determined by renal artery thickness), tobacco use (thiocyanate concentration), diabetes mellitus (DM)
(glycohemoglobin), and (in men) obesity. There was a striking increase in
both severity and extent as age and the
number of risk factors increased. By
contrast, the absence of risk factors
was shown to be associated with a virtual absence of advanced atherosclerotic lesions, even in the oldest subjects in the study.
Evidence Linking Risk Factors in
Childhood to Atherosclerosis
Assessed Noninvasively
Over the last decade, measures of subclinical atherosclerosis have developed, including the demonstration of
coronary calcium on electron beam
computed tomography imaging, increased carotid intima-media thickness (CIMT) assessed with ultrasound,
endothelial dysfunction (reduced arterial dilation) with brachial ultrasound
imaging, and increased left ventricular
mass with cardiac ultrasound. These
measures have been assessed in
young people with severe abnormalities of individual risk factors:
● In adolescents with a marked eleva-
tion of low-density lipoprotein (LDL)
cholesterol level caused by familial
heterozygous hypercholesterolemia,
abnormal levels of coronary calcium,
increased CIMT, and impaired endothelial function have been found.
● Children with hypertension have
been shown to have increased CIMT,
increased left ventricular mass, and
eccentric left ventricular geometry.
● Children with type 1 DM (T1DM) have
significantly abnormal endothelial
function and, in some studies, increased CIMT.
● Children and young adults with a
family history of myocardial infarction have increased CIMT, higher
prevalence of coronary calcium,
and endothelial dysfunction.
● Endothelial dysfunction has been
shown by ultrasound and plethysmography in association with cigarette smoking (passive and active)
PEDIATRICS Volume 128, Supplement 5, December 2011
S215
and obesity. In obese children, improvement in endothelial function
occurs with regular exercise.
● Left ventricular hypertrophy at lev-
els associated with excess mortality
in adults has been found in children
with severe obesity.
Four longitudinal studies have found relationships of risk factors measured in
youth (specifically LDL cholesterol, nonHDL cholesterol and serum apolipoproteins, obesity, hypertension, tobacco
use, and DM) with measures of subclinical atherosclerosis in adulthood. In
many of these studies, risk factors measured in childhood and adolescence
were better predictors of the severity of
adult atherosclerosis than were risk factors measured at the time of the subclinical atherosclerosis study.
crease in the extent and severity of
atherosclerosis. In natural-history
studies of DM, early CVD mortality is so
consistently observed that the presence of DM is considered evidence of
vascular disease in adults. Consonant
with this evidence, in 15- to 19-year
olds in the PDAY study, the presence of
hyperglycemia was associated with
the demonstration of advanced atherosclerotic lesions of the coronary
arteries. In the PDAY study, there was
also a strong relationship between abdominal aortic atherosclerosis and tobacco use. Finally, in a 25-year followup, the presence of the metabolic
syndrome risk-factor cluster in childhood predicted clinical CVD in adult
subjects at 30 to 48 years of age.4
Evidence Linking Risk Factors in
Childhood to Clinical CVD
The Impact of Racial/Ethnic
Background and Socioeconomic
Status in Childhood on the
Development of Atherosclerosis
The most important evidence relating
risk in youth to clinical CVD is the observed association of risk factors for
atherosclerosis to clinically manifest
cardiovascular conditions. Genetic disorders related to high cholesterol are
the biological model for risk-factor impact on the atherosclerotic process.
With homozygous hypercholesterolemia, in which LDL cholesterol levels
exceed 800 mg/dL beginning in infancy,
coronary events begin in the first decade of life and life span is severely
shortened. With heterozygous hypercholesterolemia, in which LDL cholesterol levels are minimally 160 mg/dL
and typically ⬎200 mg/dL and total
cholesterol (TC) levels exceed 250
mg/dL beginning in infancy, 50% of
men and 25% of women experience
clinical coronary events by the age of
50. By contrast, genetic traits associated with low cholesterol are associated with longer life expectancy. In the
PDAY study,2 every 30 mg/dL increase
in non-HDL cholesterol level was associated with a visible incremental in-
CVD has been observed in diverse geographic areas and all racial and ethnic
backgrounds. Cross-sectional research in children has found differences according to race and ethnicity
and according to geography for prevalence of cardiovascular risk factors;
these differences are often partially
explained by differences in socioeconomic status. No group within the
United States is without a significant
prevalence of risk. Several longitudinal cohort studies referenced extensively in this report (Bogalusa Heart
Study,3 the PDAY study,2 and the Coronary Artery Risk Development in Young
Adults [CARDIA] study5) have included
racially diverse populations, and other
studies have been conducted outside
the United States. However, longitudinal data on Hispanic, Native American,
and Asian children are lacking. Clinically important differences in prevalence of risk factors exist according to
race and gender, particularly with regard to tobacco-use rates, obesity
prevalence, hypertension, and dyslipi-
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EXPERT PANEL
demia. Low socioeconomic status in
and of itself confers substantial risk.
However, evidence is not adequate for
the recommendations provided in this
report to be specific to racial or ethnic
groups or socioeconomic status.
The Impact of Risk-Factor
Clustering in Childhood on the
Development of Atherosclerosis
From a population standpoint, clustering of multiple risk factors is the most
common association with premature
atherosclerosis. The pathologic studies reviewed above clearly showed
that the presence of multiple risk factors is associated with striking evidence of an accelerated atherosclerotic process. Among the most
prevalent multiple-risk combinations
are the use of tobacco with 1 other risk
factor and the development of obesity,
which is often associated with insulin
resistance, elevated triglyceride levels, reduced HDL cholesterol levels,
and elevated BP, a combination known
in adults as the metabolic syndrome.
There is ample evidence from both
cross-sectional and longitudinal studies that the increasing prevalence of
obesity in childhood is associated with
the same obesity-related risk-factor
clustering seen in adults and that it
continues into adult life. This high-risk
combination is among the reasons
that the current obesity epidemic with
its relationship to future CVD and DM is
considered one of the most important
public health challenges in contemporary society. One other prevalent
multiple-risk combination is the association of low cardiorespiratory fitness (identified in 33.6% of adolescents in the National Health and
Nutrition Examination Surveys [NHANES]
from 1999 to 20026) with overweight
and obesity, elevated TC level and systolic BP, and a reduced HDL cholesterol
level.
SUPPLEMENT ARTICLES
Risk-Factor Tracking From
Childhood Into Adult Life
Tracking studies from childhood to
adulthood have been performed for all
the major risk factors.
● Obesity tracks more strongly than
any other risk factor; among many
reports from studies that have demonstrated this fact, one of the most
recent is from the Bogalusa study,7
in which ⬎2000 children were followed from initial evaluation at 5 to
14 years of age to adult follow-up at
a mean age of 27 years. On the basis
of BMI percentiles derived from the
study population, 84% of those with
a BMI in the 95th to 99th percentile
as children were obese as adults,
and all of those with a BMI at the
⬎99th percentile were obese in
adulthood. Increased correlation is
seen with increasing age at which
the elevated BMI occurs.
● For cholesterol and BP, tracking
correlation coefficients in the range
of 0.4 have been reported consistently from many studies, correlating these measures in children 5 to
10 years of age with results 20 to 30
years later. These data suggest that
having cholesterol or BP levels in
the upper portion of the pediatric
distribution makes having them as
adult risk factors likely but not certain. Those who develop obesity
have been shown to be more likely
to develop hypertension or dyslipidemia as adults.
● Tracking data on physical fitness
are more limited. Physical activity
levels do track but not as strongly
as other risk factors.
● By its addictive nature, tobacco use
persists into adulthood, although
⬃50% of those who have ever
smoked eventually quit.
● T1DM is a lifelong condition.
● The insulin resistance of T2DM can be
alleviated by exercise, weight loss, and
bariatric surgery, but the long-term outcome of those with T2DM diagnosed in
childhood is not known.
● As already discussed, risk-factor
clusters such as those seen with
obesity and the metabolic syndrome
have been shown to track from
childhood into adulthood.
CVD Prevention Beginning in Youth
The rationale for these guidelines
comes from the following evidence.
● Atherosclerosis, the pathologic ba-
sis for clinical CVD, originates in
childhood.
● Risk factors for the development of
atherosclerosis can be identified in
childhood.
● Development and progression of
atherosclerosis clearly relates to
the number and intensity of cardiovascular risk factors, which begin in
childhood.
● Risk factors track from childhood
into adult life.
● Interventions exist for the manage-
ment of identified risk factors.
The evidence for the first 4 bullet
points is reviewed in this section, and
the evidence surrounding interventions for identified risk factors is addressed in the risk-factor–specific
sections of the guideline to follow.
It is important to distinguish between
the goals of prevention at a young age
and those at older ages in which atherosclerosis is well established, morbidity may already exist, and the process is only minimally reversible. At a
young age, there have historically been
2 goals of prevention: (1) prevent the
development of risk factors (primordial prevention); and (2) recognize and
manage those children and adolescents who are at increased risk as a
result of the presence of identified risk
factors (primary prevention). It is well
established that a population that enters adulthood with lower risk will
have less atherosclerosis and will collectively have lower CVD rates. This
concept is supported by research that
has found that (1) societies with low
levels of cardiovascular risk factors
have low CVD rates and that changes
in risk in those societies are associated with a change in CVD rates, (2)
in adults, control of risk factors
leads to a decline in morbidity and
mortality from CVD, and (3) those
without childhood risk have minimal
atherosclerosis at 30 to 34 years of
age, absence of subclinical atherosclerosis as young adults, extended
life expectancy, and a better quality
of life free from CVD.
The Pathway to Recommending
Clinical Practice-Based Prevention
The most direct means of establishing
evidence for active CVD prevention beginning at a young age would be to randomly assign young people with
defined risks to treatment of cardiovascular risk factors or to no treatment and follow both groups over
sufficient time to determine if cardiovascular events are prevented without
undue increase in morbidity arising
from treatment. This direct approach
is intellectually attractive, because
atherosclerosis prevention would begin at the earliest stage of the disease
process and thereby maximize the
benefit. However, this approach is as
unachievable as it is attractive, primarily because such studies would be
extremely expensive and would be several decades in duration, a time period
in which changes in environment and
medical practice would diminish the
relevance of the results.
The recognition that evidence from
this direct pathway is unlikely to be
achieved requires an alternative stepwise approach in which segments of
an evidence chain are linked in a manner that serves as a sufficiently rigorous proxy for the causal inference of a
PEDIATRICS Volume 128, Supplement 5, December 2011
S217
clinical trial. The evidence reviewed in
this section provides the critical rationale for cardiovascular prevention beginning in childhood: atherosclerosis
begins in youth; the atherosclerotic
process relates to risk factors that can
be identified in childhood; and the
presence of these risk factors in a
given child predicts an adult with risk
if no intervention occurs. The remaining evidence links pertain to the demonstration that interventions to lower
risk will have a health benefit and that
the risk and cost of interventions to
improve risk are outweighed by the reduction in CVD morbidity and mortality. These issues are captured in the
evidence reviews of each risk factor.
The recommendations reflect a complex decision process that integrates
the strength of the evidence with
knowledge of the natural history of
atherosclerotic vascular disease, estimates of intervention risk, and the physician’s responsibility to provide both
health education and effective disease
treatment. These recommendations
for those caring for children will be
most effective when complemented by
a broader public health strategy.
The Childhood Medical Office Visit
as the Setting for Cardiovascular
Health Management
One cornerstone of pediatric care is
placing clinical recommendations in a
developmental context. Those who
make pediatric recommendations
must consider not only the relation of
age to disease expression but the ability of the patient and family to understand and implement medical advice.
For each risk factor, recommendations must be specific to age and developmental stage. The Bright Futures
concept of the American Academy of
Pediatrics8 (AAP) is used to provide a
framework for these guidelines with
cardiovascular risk-reduction recommendations for each age group.
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EXPERT PANEL
This document provides recommendations for preventing the development
of risk factors and optimizing cardiovascular health, beginning in infancy,
that are based on the results of the
evidence review. Pediatric care providers (pediatricians, family practitioners, nurses, nurse practitioners,
physician assistants, registered dietitians) are ideally positioned to reinforce cardiovascular health behaviors
as part of routine care. The guideline
also offers specific guidance on primary prevention with age-specific,
evidence-based recommendations for
individual risk-factor detection. Management algorithms provide staged
care recommendations for risk reduction within the pediatric care setting
and identify risk-factor levels that require specialist referral. The guidelines also identify specific medical conditions such as DM and chronic kidney
disease that are associated with increased risk for accelerated atherosclerosis. Recommendations for
ongoing cardiovascular health management for children and adolescents
with these diagnoses are provided.
A cornerstone of pediatric care is the
provision of health education. In the US
health care system, physicians and
nurses are perceived as credible messengers for health information. The
childhood health maintenance visit
provides an ideal context for effective
delivery of the cardiovascular health
message. Pediatric care providers
provide an effective team educated to
initiate behavior change to diminish
risk of CVD and promote lifelong cardiovascular health in their patients
from infancy into young adult life.
3. CARDIOVASCULAR HEALTH
SCHEDULE (p. S219)
4. FAMILY HISTORY OF EARLY
ATHEROSCLEROTIC CVD
A family history of CVD represents the
net effect of shared genetic, biochemi-
cal, behavioral, and environmental
components. In adults, epidemiologic
studies have found that a family history of premature coronary heart disease in a first-degree relative (heart
attack, treated angina, percutaneous
coronary catheter interventional procedure, coronary artery bypass surgery, stroke, or sudden cardiac death
in a male parent or sibling before the
age of 55 years or a female parent or
sibling before the age of 65 years) is an
important independent risk factor for
future CVD. The process of atherosclerosis is complex and involves many genetic loci and multiple environmental
and personal risk factors. Nonetheless, the presence of a positive parental history has been consistently found
to significantly increase baseline risk
for CVD. The risk for CVD in offspring is
strongly inversely related to the age of
the parent at the time of the index
event. The association of a positive
family history with increased cardiovascular risk has been confirmed for
men, women, and siblings and in different racial and ethnic groups. The evidence review identified all RCTs, systematic reviews, meta-analyses, and
observational studies that addressed
family history of premature atherosclerotic disease and the development
and progression of atherosclerosis
from childhood into young adult life.
Conclusions and Grading of the
Evidence Review for the Role of
Family History in Cardiovascular
Health
● Evidence from observational stud-
ies strongly supports inclusion of a
positive family history of early coronary heart disease in identifying
children at risk for accelerated atherosclerosis and for the presence of
an abnormal risk profile (grade B).
● For adults, a positive family history
is defined as a parent and/or sibling
with a history of treated angina,
PEDIATRICS Volume 128, Supplement 5, December 2011
Encourage parents to
model routine activity;
no screen time before
the age of 2 y
—
Physical
activity
Diabetes
—
Encourage active play; limit
sedentary/screen time to ⱕ2
h/d; no TV in bedroom
Measure BP annually in all from
the age of 3 y; chart for age/
gender/height percentile and
review with parent
Obtain FLP only if family history
for CVD is positive, parent has
dyslipidemia, child has any
other RFs or high-risk
condition
Chart height/weight/BMI;
classify weight-by BMI from
age 2 y; review with parent
—
Recommend MVPA of ⱖ1 h/d;
limit screen/sedentary time
to ⱕ2 h/d
Check BP annually and chart for
age/gender/height: review
with parent; workup and/or
management per BP
algorithm as needed
Obtain FLP only if family history
for CVD is positive, parent
has dyslipidemia, child has
any other RFs or high-risk
condition
Chart height/weight/BMI and
review with parent; BMI ⱖ
85th percentile, crossing
percentiles: Intensify diet/
activity focus for 6 mo; if no
change: RD referral, manage
per obesity algorithms
BMI ⱖ 95th percentile, manage
per obesity algorithms
Reinforce CHILD-1 diet messages
Obtain smoke exposure history
from child Begin active
antismoking advice with child
5–9 y
Update at each nonurgent health
encounter
Measure fasting glucose level per
ADA guidelines; refer to
endocrinologist as needed
Obtain activity history from child:
recommend MVPA of ⱖ1 h/d
and screen/sedentary time of
ⱕ2 h/d
Check BP annually and chart for
age/gender/height: review with
parent, workup and/or
management per BP algorithm
as needed
Obtain universal lipid screen with
nonfasting non-HDL ⫽ TC ⫺
HDL, or FLP: manage per lipid
algorithms as needed
Chart height/weight/BMI and
review with parent and child;
BMI ⱖ 85th percentile,
crossing percentiles: Intensify
diet/activity focus for 6 mo; if
no change: RD referral,
manage per obesity
algorithms; BMI ⱖ 95th
percentile: manage per obesity
algorithms
Reinforce CHILD-1 diet messages
as needed
Assess smoking status of child;
active antismoking counseling
or referral as needed
9–11 y
Reevaluate family history for early
CVD in parents, grandparents,
aunts/uncles, men ⱕ55 y old,
women ⱕ65 y old
Age
Measure fasting glucose level per
ADA guidelines; refer to
endocrinologist as needed
Use activity history with adolescent
to reinforce MVPA of ⱖ1 h/d and
leisure screen time of ⱕ2 h/d
Check BP annually and chart for
age/gender/height: review with
adolescent and parent, workup
and/or management per BP
algorithm as needed
Obtain FLP if family history newly
positive, parent has
dyslipidemia, child has any other
RFs or high-risk condition;
manage per lipid algorithms as
needed
Chart height/weight/BMI and review
with child and parent; BMI ⱖ85th
percentile, crossing percentiles:
intensify diet/activity focus for 6
mo; if no change: RD referral,
manage per obesity algorithms;
BMI ⱖ 95th percentile, manage
per obesity algorithms
Obtain diet information from child
and use to reinforce healthy diet
and limitations and provide
counseling as needed
Continue active antismoking
counseling with patient; offer
smoking-cessation assistance or
referral as needed
12–17 y
Update at each nonurgent health
encounter
Obtain fasting glucose level if indicated;
refer to endocrinologist as needed
Discuss lifelong activity, sedentary time
limits with patient
Measure BP: review with patient;
evaluate and treat per JNC guidelines
Measure 1 nonfasting non–HDL or FLP in
all: review with patient; manage with
lipid algorithms per ATP as needed
Review height/weight/BMI and norms for
health with patient; BMI ⱖ 85th
percentile, crossing percentiles:
intensify diet/activity focus for 6 mo;
if no change: RD referral, manage per
obesity algorithms; BMI ⱖ 95th
percentile, manage per obesity
algorithms
Review healthy diet with patient
Reinforce strong antismoking message;
offer smoking-cessation assistance or
referral as needed
18–21 y
Repeat family-history evaluation with
patient
All algorithms and guidelines in this schedule are included in this summary report. RF indicates risk factor; RD, registered dietitian; ATP, Adult Treatment Panel III (“Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood
Cholesterol in Adults”); JNC, Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; MVPA, moderate-to-vigorous physical activity; ADA, American Diabetes Association.
The full and summary reports of the Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents can also be found on the NHLBI Web site (www.nhlbi.nih.gov).
Measure BP in infants with
renal/urologic/cardiac
diagnosis or history of
neonatal ICU
BP
Review family history for
obesity; discuss weightfor-height tracking,
growth chart, and
healthy diet
Growth,
overweight/
obesity
No routine lipid screening
Support breastfeeding as
optimal to 12 mo of age
if possible; add formula
if breastfeeding
decreases or stops
before 12 mo of age
Nutrition/diet
Lipids
Continue active antismoking
advice with parents; offer
smoking-cessation assistance
and referral as needed
Advise smoke-free home;
offer smoking-cessation
assistance or referral
to parents
Tobacco
exposure
At age 12–24 mo, may change to
cow’s milk with 2%
percentage of fat decided by
family and pediatric care
provider; after 2 y of age,
fat-free milk for all; juice ⱕ4
oz/d; transition to CHILD-1
diet by the age of 2 y
1–4 y
At 3 y, evaluate family history for
early CVD: parents, grandparents, aunts/uncles, men
ⱕ55 y old, women ⱕ65 y old;
review with parents and refer
as needed; positive family
history identifies children for
intensive CVD RF attention
Birth to 12 mo
—
Family
history of
early CVD
Risk Factor
3. INTEGRATED CARDIOVASCULAR HEALTH SCHEDULE
SUPPLEMENT ARTICLES
S219
myocardial infarction, percutaneous coronary catheter interventional procedure, coronary artery
bypass grafting, stroke, or sudden
cardiac death before 55 years in
men or 65 years in women. Because
the parents and siblings of children
and adolescents are usually young
themselves, it was the panel consensus that when evaluating family
history of a child, history should
also be ascertained for the occurrence of CVD in grandparents,
aunts, and uncles, although the evidence supporting this recommendation is insufficient to date (grade
D).
● Identification of a positive family
history for cardiovascular disease
and/or cardiovascular risk factors should lead to evaluation of
all family members, especially
parents, for cardiovascular risk
factors (grade B).
● Family history evolves as a child ma-
tures, so regular updates are a necessary part of routine pediatric
care (grade D).
● Education about the importance of
accurate and complete family
health information should be part of
routine care for children and adolescents. As genetic sophistication
increases, linking family history to
specific genetic abnormalities will
provide important new knowledge
about the atherosclerotic process
(grade D).
Recommendations for the use of family history in cardiovascular health
promotion are listed in Table 4-1.
5. NUTRITION AND DIET
The 2010 Dietary Guidelines for Americans (DGA)8 include important recommendations for the population aged 2
years and older. In 1992, the National
Cholesterol Education Program (NCEP)
Pediatric Panel report1 provided dietary recommendations for all chil-
S220
EXPERT PANEL
dren as part of a population-based approach to reducing cardiovascular
risk. Evidence relative to diet and the
development of atherosclerosis in
childhood and adolescence was identified by the evidence review for this
guideline and, collectively, provides
the rationale for new dietary prevention efforts initiated early in life.
This new pediatric cardiovascular
guideline not only builds on the recommendations for achieving nutrient adequacy in growing children as stated
in the 2010 DGA but also adds evidence
regarding the efficacy of specific dietary changes in reducing cardiovascular risk from the current evidence
review for use by pediatric care providers in the care of their patients. Because the focus of these guidelines is
on cardiovascular risk reduction, the
evidence review specifically evaluated
dietary fatty acid and energy components as major contributors to hypercholesterolemia and obesity, as well
as dietary composition and micronutrients as they affect hypertension.
New evidence from multiple dietary trials that addressed cardiovascular risk
reduction in children has provided
important information for these
recommendations.
conclusions of the expert panel’s review of the entire body of evidence in a
specific nutrition area with grades are
summarized. Where the evidence is inadequate yet nutrition guidance is
needed, recommendations for pediatric care providers are based on a consensus of the expert panel (grade D).
The age- and evidence-based recommendations of the expert panel follow.
In accordance with the Surgeon General’s Office, the World Health Organization, the AAP, and the American
Academy of Family Physicians, exclusive breastfeeding is recommended
for the first 6 months of life. Continued breastfeeding is recommended
to at least 12 months of age with the
addition of complementary foods. If
breastfeeding per se is not possible,
feeding human milk by bottle is second best, and formula-feeding is the
third choice.
● Long-term follow-up studies have
found that subjects who were breastfed have sustained cardiovascular
health benefits, including lower cholesterol levels, lower BMI, reduced
prevalence of type 2 DM, and lower
CIMT in adulthood (grade B).
● Ongoing nutrition counseling has
Conclusions and Grading of the
Evidence Review for Diet and
Nutrition in Cardiovascular Risk
Reduction
The expert panel concluded that there
is strong and consistent evidence that
good nutrition beginning at birth has
profound health benefits and the potential to decrease future risk for CVD.
The expert panel accepts the 2010 DGA8
as containing appropriate recommendations for diet and nutrition in children aged 2 years and older. The recommendations in these guidelines are
intended for pediatric care providers
to use with their patients to address
cardiovascular risk reduction. The
been effective in assisting children
and families to adopt and sustain
recommended diets for both nutrient adequacy and reducing cardiovascular risk (grade A).
● Within appropriate age- and gender-
based requirements for growth and
nutrition, in normal children and in
children with hypercholesterolemia
intake of total fat can be safely limited to 30% of total calories, saturated fat intake limited to 7% to 10%
of calories, and dietary cholesterol
limited to 300 mg/day. Under the
guidance of qualified nutritionists,
this dietary composition has been
shown to result in lower TC and LDL
SUPPLEMENT ARTICLES
cholesterol levels, less obesity, and
less insulin resistance (grade A).
Under similar conditions and with
ongoing follow-up, these levels of fat
intake might have similar effects
starting in infancy (grade B). Fats
are important to infant diets because of their role in brain and cognitive development. Fat intake for infants younger than 12 months
should not be restricted without
medical indication.
● The remaining 20% of fat intake
should comprise a combination of
monosaturated and polyunsaturated fats (grade D). Intake of trans
fats should be limited as much as
possible (grade D).
● For adults, the current NCEP guide-
lines9 recommend that adults consume 25% to 35% of calories from
fat. The 2010 DGA supports the Institute of Medicine recommendations
for 30% to 40% of calories from fat
for ages 1 to 3 years, 25% to 35% of
calories from fat for ages 4 to 18
years, and 20% to 35% of calories
from fat for adults. For growing children, milk provides essential nutrients, including protein, calcium,
magnesium, and vitamin D, that are
not readily available elsewhere in
the diet. Consumption of fat-free
milk in childhood after 2 years of
age and through adolescence optimizes these benefits without compromising nutrient quality while
avoiding excess saturated fat and
calorie intake (grade A). Between
the ages of 1 and 2 years, as children transition from breast milk or
formula, reduced-fat milk (ranging
from 2% milk to fat-free milk) can be
used on the basis of the child’s
growth, appetite, intake of other
nutrient-dense foods, intake of
other sources of fat, and risk for
obesity and CVD. Milk with reduced
fat should be used only in the context of an overall diet that supplies
30% of calories from fat. Dietary intervention should be tailored to
each specific child’s needs.
● Optimal intakes of total protein and
total carbohydrate in children were
not specifically addressed, but with
a recommended total fat intake of
30% of energy, the expert panel recommends that the remaining 70% of
calories include 15% to 20% from
protein and 50% to 55% from carbohydrate sources (no grade). These
recommended ranges fall within
the acceptable macronutrient distribution range specified by the
2010 DGA: 10% to 30% of calories
from protein and 45% to 65% of calories from carbohydrate for children aged 4 to 18 years.
● Sodium intake was not addressed by
the evidence review for this section on
nutrition and diet. From the evidence
review for the “High BP” section,
lower sodium intake is associated
with lower systolic and diastolic BP in
infants, children, and adolescents.
cal activity needs (grade A). Estimated calorie requirements according to gender and age group at
3 levels of physical activity from the
dietary guidelines are shown in Table 5-2. For children of normal
weight whose activity is minimal,
most calories are needed to meet nutritional requirements, which leaves
only ⬃5% to 15% of calorie intake
from extra calories. These calories
can be derived from fat or sugar
added to nutrient-dense foods to allow their consumption as sweets, desserts, or snack foods (grade D).
● Dietary fiber intake is inversely as-
sociated with energy density and increased levels of body fat and is positively associated with nutrient
density (grade B); a daily total dietary fiber intake from food sources
of at least age plus 5 g for young
children up to 14 g/1000 kcal for
older children and adolescents is
recommended (grade D).
● The expert panel supports the 2008
calorie sources of nutrients including
vitamins and fiber in the diets of children; increasing access to fruits and
vegetables has been shown to increase their intake (grade A). However, increasing fruit and vegetable
intake is an ongoing challenge.
AAP recommendation for vitamin D
supplementation with 400 IU/day for
all infants and children.10 No other
vitamin, mineral, or dietary supplements are recommended (grade D).
The new recommended daily allowance for vitamin D for those aged 1
to 70 years is 600 IU/day.
● Reduced intake of sugar-sweetened
● Use of dietary patterns modeled on
beverages is associated with decreased obesity measures (grade B).
Specific information about fruit juice
intake is too limited for an evidencebased recommendation. Recommendations for intake of 100% fruit juice
by infants was made by a consensus
of the expert panel (grade D) and are
in agreement with those of the AAP.
those shown to be beneficial for
adults (eg, Dietary Approaches to
Stop Hypertension [DASH] pattern)
is a promising approach to improving nutrition and decreasing cardiovascular risk (grade B).
● Plant-based foods are important low-
● Per the 2010 DGA, energy intake
should not exceed energy needed
for adequate growth and physical
activity. Calorie intake needs to
match growth demands and physi-
● All diet recommendations must be
interpreted for each child and family to address individual diet patterns and patient sensitivities such
as lactose intolerance and food allergies (grade D).
Graded, age-specific recommendations for pediatric care providers to
PEDIATRICS Volume 128, Supplement 5, December 2011
S221
TABLE 4-1 Evidence-Based Recommendations for Use of Family History in Cardiovascular
Health Promotion
Birth to 18 y Take detailed family history of CVD at initial encounter and/or at 3,
9–11, and 18 ya
Grade B
Recommend
If positive family history identified, evaluate patient for other
cardiovascular risk factors, including dyslipidemia, hypertension,
DM, obesity, history of smoking, and sedentary lifestyle
If positive family history and/or cardiovascular risk factors identified, Grade B
evaluate family, especially parents, for cardiovascular risk factors Recommend
Update family history at each nonurgent health encounter
Grade D
Recommend
Use family history to stratify risk for CVD risk as risk profile evolves
Grade D
Recommend
Supportive action: educate parents about the importance of family
history in estimating future health risks for all family members
18 to 21 y
Review family history of heart disease with young adult patient
Grade B
Strongly recommend
Supportive action: educate patient about family/personal risk for
early heart disease, including the need for evaluation for all
cardiovascular risk factors
Grades reflect the findings of the evidence review; recommendation levels reflect the consensus opinion of the expert
panel; and supportive actions represent expert consensus suggestions from the expert panel provided to support
implementation of the recommendations (they are not graded).
a “Family” includes parent, grandparent, aunt, uncle, or sibling with heart attack, treated angina, coronary artery bypass
graft/stent/angioplasty, stroke, or sudden cardiac death at ⬍55 y in males and ⬍65 y in females.
use in optimizing cardiovascular
health in their patients are summarized in Table 5-1. The Cardiovascular
Health Integrated Lifestyle Diet
(CHILD-1) is the first stage in dietary
change for children with identified dyslipidemia, overweight and obesity,
risk-factor clustering, and high-risk
medical conditions that might ultimately require more intensive dietary
change. CHILD-1 is also the recommended diet for children with a positive family history of early cardiovascular disease, dyslipidemia, obesity,
primary hypertension, DM, or exposure to smoking in the home. Any dietary modification must provide nutrients and calories needed for optimal
growth and development (Table 5-2).
Recommended intakes are adequately
met by a DASH-style eating plan, which
emphasizes fat-free/low-fat dairy and
increased intake of fruits and vegetables. This diet has been modified for
use in children aged 4 years and older
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EXPERT PANEL
on the basis of daily energy needs according to food group and is shown in
Table 5-3 as an example of a hearthealthy eating plan using CHILD-1
recommendations.
6. PHYSICAL ACTIVITY
Physical activity is any bodily movement produced by contraction of skeletal muscle that increases energy expenditure above a basal level. Physical
activity can be focused on strengthening muscles, bones, and joints, but because these guidelines address cardiovascular health, the evidence
review concentrated on aerobic activity and on the opposite of activity: sedentary behavior. There is strong evidence for beneficial effects of physical
activity and disadvantageous effects of
a sedentary lifestyle on the overall
health of children and adolescents
across a broad array of domains. Our
review focused on the effects of activity on cardiovascular health, because
physical inactivity has been identified
as an independent risk factor for coronary heart disease in adults. Over the
last several decades, there has been a
steady decrease in the amount of time
that children spend being physically
active and an accompanying increase
in time spent in sedentary activities. The
evidence review identified many studies
in youth ranging in age from 4 to 21 years
that strongly linked increased time
spent in sedentary activities with reduced overall activity levels, disadvantageous lipid profiles, higher systolic BP,
higher levels of obesity, and higher levels
of all the obesity-related cardiovascular
risk factors including hypertension, insulin resistance, and type 2 DM.
Conclusions and Grading of the
Evidence Review for Physical
Activity
The expert panel felt that the evidence
strongly supports the role of physical
activity in optimizing cardiovascular
health in children and adolescents.
● There is reasonably good evidence
that physical activity patterns established in childhood are carried forward into adulthood (grade C).
● There is strong evidence that in-
creases in moderate-to-vigorous
physical activity are associated with
lower systolic and diastolic BP, decreased measures of body fat, decreased BMI, improved fitness measures, lower TC level, lower LDL
cholesterol level, lower triglyceride
level, higher HDL cholesterol level,
and decreased insulin resistance in
childhood and adolescence (grade
A).
● There is limited but strong and con-
sistent evidence that physical exercise interventions improve subclinical measures of atherosclerosis
(grade B).
● Physical activity patterns, dietary
choices, and smoking behaviors
cluster together (grade C).
SUPPLEMENT ARTICLES
TABLE 5-1 Evidence-Based Recommendations for Diet and Nutrition: CHILD-1
Birth to 6 mo
Infants should be exclusively breastfed (no supplemental formula or other foods) until the age of 6 moa
Grade B
Strongly recommend
6 to 12 mo
Continue breastfeeding until at least 12 mo of age while gradually adding solids; transition to ironfortified formula until 12 mo if reducing breastfeedinga
Fat intake in infants ⬍12 mo of age should not be restricted without medical indication
Grade B
Strongly recommend
Grade D
Recommend
Grade D
recommend
Limit other drinks to 100% fruit juice (ⱕ4 oz/d); no sweetened beverages; encourage water
12 to 24 mo
Transition to reduced-fatb (2% to fat-free) unflavored cow’s milkc (see supportive actions)
Limit/avoid sugar-sweetened beverage intake; encourage water
Transition to table food with:
Total fat 30% of daily kcal/EERd
Grade B
Recommend
Grade B
Strongly recommend
Grade B
Recommend
Grade B
Recommend
Grade D
Strongly recommend
Grade D
recommend
Grade B
Strongly recommend
Saturated fat 8%–10% of daily kcal/EER
Avoid trans fat as much as possible
Monounsaturated and polyunsaturated fat up to 20% of daily kcal/EER
Cholesterol ⬍ 300 mg/d
Supportive actions
The fat content of cow’s milk to introduce at 12–24 mo of age should be decided together by parents
and health care providers on the basis of the child’s growth, appetite, intake of other nutrient-dense
foods, intake of other sources of fat, and potential risk for obesity and CVD
100% fruit juice (from a cup), no more than 4 oz/d
Limit sodium intake
Consider DASH-type diet rich in fruits, vegetables, whole grains, and low-fat/fat-free milk and milk
products and lower in sugar (Table 5-3)
2 to 10 y
Primary beverage: fat-free unflavored milk
Grade A
Strongly recommend
Grade B
Recommend
Limit/avoid sugar-sweetened beverages; encourage water
Fat content:
Total fat 25%–30% of daily kcal/EER
Grade A
Strongly recommend
Grade A
Strongly recommend
Grade D, recommend
Grade D
Recommend
Grade A
Strongly Recommend
Grade B
recommend
Saturated fat 8%–10% of daily kcal/EER
Avoid trans fats as much as possible
Monounsaturated and polyunsaturated fat up to 20% of daily kcal/EER
Cholesterol ⬍ 300 mg/d
Encourage high dietary fiber intake from foodse
Supportive actions:
Teach portions based on EER for age/gender/age (Table 5-2)
Encourage moderately increased energy intake during periods of rapid growth and/or regular
moderate-to-vigorous physical activity
Encourage dietary fiber from foods: age ⫹ 5 g/de
Limit naturally sweetened juice (no added sugar) to 4 oz/d
Limit sodium intake
Support DASH-style eating plan (Table 5-3)
11 to 21 y
Primary beverage: fat-free unflavored milk
Limit/avoid sugar-sweetened beverages; encourage water
Grade A
Strongly recommend
Grade B
Recommend
PEDIATRICS Volume 128, Supplement 5, December 2011
S223
TABLE 5-1 Continued
Fat content:
Total fat 25%–30% of daily kcal/EERd
Grade A
Strongly recommend
Grade A
Strongly recommend
Grade D
Recommend
Grade D
Recommend
Grade A
Strongly recommend
Grade B
Recommend
Saturated fat 8%–10% of daily kcal/EER
Avoid trans fat as much as possible
Monounsaturated and polyunsaturated fat up to 20% of daily kcal/EER
Cholesterol ⬍ 300 mg/d
Encourage high dietary fiber intake from foodse
Supportive actions:
Teach portions based on EER for age/gender/activity (Table 5-2)
Encourage moderately increased energy intake during periods of rapid growth and/or regular
moderate-to-vigorous physical activity
Advocate dietary fiber: goal of 14 g/1000 kcale
Limit naturally sweetened juice (no added sugar) to 4–6 oz/d
Limit sodium intake
Encourage healthy eating habits: breakfast every day, eating meals as a family, limiting fast-food meals
Support DASH-style eating plan (Table 5-3)
Grades reflect the findings of the evidence review; recommendation levels reflect the consensus opinion of the expert panel. Supportive actions represent expert consensus suggestions
from the expert panel provided to support implementation of the recommendations; they are not graded. EER indicates estimated energy requirement.
a Infants who cannot be fed directly at the breast should be fed expressed milk. Infants for whom expressed milk is not available should be fed iron-fortified infant formula.
b For toddlers 12 to 24 mo of age with a family history of obesity, heart disease, or high cholesterol, parents should discuss transition to reduced-fat milk with pediatric care provider after
12 months of age.
c Continued breastfeeding is still appropriate and nutritionally superior to cow’s milk. Reduced-fat milk should be used only in the context of an overall diet that supplies 30% of calories from fat.
d Estimated energy requirements per day for age/gender (Table 5-2).
e Naturally fiber-rich foods are recommended (fruits, vegetables, whole grains); fiber supplements are not advised. Limit refined carbohydrates (sugars, white rice, and white bread).
● There is no evidence of harm assoTABLE 5-2 Estimated Calorie Needs per Day by Age, Gender, and Physical Activity Levela
Gender
Child
Femaled
Male
Age
(Years)
2–3
4–8
9–13
14–18
19–30
4–8
9–13
14–18
19–30
Calorie Requirements (kcals) by Activity Levelb
Sedentary
Moderately
Active
Active
1000–1200
1200–1400
1400–1600
1800
1800–2000
1200–1400
1600–2000
2000–2400
2400–2600
1000–1400c
1400–1600
1600–2000
2000
2000–2200
1400–1600
1800–2200
2400–2800
2600–2800
1000–1400c
1400–1800
1800–2200
2400
2400
1600–2000
2000–2600
2800–3200
3000
Estimated amounts of calories needed to maintain caloric balance for various gender and age groups at three different
levels of physical activity. The estimates are rounded to the nearest 200 calories. An individual’s calorie needs may be higher
or lower than these average estimates.
a Based on Estimated Energy Requirements (EER) equations, using reference heights (average) and reference weights
(health) for each age/gender group. For children and adolescents, reference height and weight vary. For adults, the
reference man is 5 feet 10 inches tall and weighs 154 pounds. The reference woman is 5 feet 4 inches tall and weighs 126
pounds. EER equations are from the Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat,
Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington (DC): The National Academies Press; 2002.
b Sedentary means a lifestyle that includes only the light physical activity associated with typical day-to-day life. Moderately
active means a lifestyle that includes physical activity equivalent to walking ⬃1.5 to 3 miles per day at 3 to 4 miles per hour,
in addition to the light physical activity associated with typical day-to-day life. Active means a lifestyle that includes physical
activity equivalent to walking ⬎3 miles per day at 3 to 4 miles per hour, in addition to the light physical activity associated
with typical day-to-day life.
c The calorie ranges shown are to accommodate needs of different ages within the group. For children and adolescents,
more calories are needed at older ages. For adults, fewer calories are needed at older ages.
d Estimates for females do not include women who are pregnant or breastfeeding.
Reproduced with permission from Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat,
Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academies Press; 2002:175–182.
S224
EXPERT PANEL
ciated with increased physical activity or limitation of sedentary activity
in healthy children (grade A).
● There is strong evidence that physi-
cal activity should be promoted in
schools (grade A).
There is less specific information on
the type and amount of physical exercise required for optimum cardiovascular health. Reported activity interventions ranged from 20 to 60 minutes,
2 to 5 times per week in children aged
3 to 17 years and included a wide variety of dynamic and isometric exercises. Extrapolating from these
interventions, which occurred in supervised settings, to the real world of
childhood and adolescence, the expert panel recommends at least 1
hour of moderate-to-vigorous activity every day of the week for children
older than 5 years (Table 6-1). In
agreement with the “Physical Activity
Guidelines Advisory Committee Re-
SUPPLEMENT ARTICLES
TABLE 5-3 DASH Eating Plan: Servings per Day According to Food Group and Total Energy Intake
Food Group
No. of Servings
Serving Size
Examples and Notes
1200
cal
1400
cal
1600
cal
1800
cal
2000
cal
Grainsa
4–5/d
5–6/d
6/d
6/d
6–8/d
Vegetables
3–4/d
3–4/d
3–4/d
4–5/d
4–5/d
5–6/d 1 cup raw leafy
vegetable; 1⁄2 cup
cut-up raw or
cooked vegetable;
1⁄2 cup vegetable
juice
Fruits
3–4/d
4/d
4/d
4–5/d
4–5/d
5–6/d 1 medium fruit; 1⁄4 cup Apples, apricots, bananas,
dried fruit; 1⁄2 cup
dates, grapes, oranges,
grapefruit, grapefruit
fresh, frozen, or
juice, mangoes, melons,
canned fruit; 1⁄2 cup
fruit juice
peaches, pineapples,
raisins, strawberries,
tangerines
Fat-free or lowfat milk and
milk products
2–3/d
2–3/d
2–3/d
2–3/d
2–3/d
Lean meats,
poultry, and
fish
ⱕ3/d
ⱕ3–4/d ⱕ3–4/d
ⱕ6/d
ⱕ6/d
Nuts, seeds, and
legumes
3/wk
3/wk
Fats and oilsd
1/d
1/d
2/d
ⱕ3/wk
ⱕ3/wk
ⱕ3/wk
Sweets and
added sugars
3–4/wk
4/wk
2600
cal
Significance of Each
Food Group to the
DASH Eating Plan
10–11/d 1 slice bread; 1 oz dry Whole-wheat bread and rolls, Major sources of energy
cerealb; 1⁄2 cup
whole-wheat pasta,
and fiber
cooked rice, pasta,
English muffin, pita bread,
or cerealb
bagel, cereals, grits,
oatmeal, brown rice,
unsalted pretzels and
popcorn
3/d 1 cup milk or yogurt;
11⁄2 oz cheese
ⱕ6/d 1 oz cooked meats,
poultry, or fish; 1
eggc
Broccoli, carrots, collards,
Rich sources of
green beans, green peas,
potassium,
kale, lima beans, potatoes,
magnesium, and fiber
spinach, squash, sweet
potatoes, tomatoes
Fat-free milk or buttermilk,
fat-free, low-fat, or
reduced-fat cheese, fatfree/low-fat regular or
frozen yogurt
Important sources of
potassium,
magnesium, and fiber
Major sources of
calcium and protein
Select only lean; trim away
Rich sources of protein
visible fats; broil, roast, or
and magnesium
poach; remove skin from
poultry
13
⁄ cup or 11⁄2 oz nuts; Almonds, filberts, mixed nuts, Rich sources of energy,
peanuts, walnuts,
magnesium, protein,
2 tbsp peanut
sunflower seeds, peanut
and fiber
butter; 2 tbsp or 1⁄2
oz seeds; 1⁄2 cup
butter, kidney beans,
cooked legumes
lentils, split peas
(dry beans and
peas)
4–5/wk
1/d
2–3/d
2–3/d
3/d 1 tsp soft margarine; Soft margarine, vegetable oil The DASH study had 27%
1 tsp vegetable oil;
(such as canola, corn,
of calories as fat,
1 tbsp mayonnaise;
olive, or safflower), low-fat
including fat in or
2 tbsp salad
mayonnaise, light salad
added to foods
dressing
dressing
ⱕ5/wk
ⱕ5/wk
ⱕ2/d 1 tbsp sugar; 1 tbsp
jelly or jam; 1⁄2 cup
sorbet, gelatin; 1
cup lemonade
Fruit-flavored gelatin, fruit
punch, hard candy, jelly,
maple syrup, sorbet and
ices, sugar
Sweets should be low in
fat
Table 5-2 provides estimated energy requirements according to age, gender, and activity level for use with this table. The FDA and the Environmental Protection Agency advise women of
childbearing age who may become pregnant, pregnant women, nursing mothers, and young children to avoid some types of fish and shellfish and eat fish and shellfish that are low in
mercury. For more information, call the FDA’s food information line toll free at 1-888-SAFEFOOD or visit www.cfsan.fda.gov/~dms/admehg3.html.
a Whole grains are recommended for most grain servings as a good source of fiber and nutrients.
b Serving sizes vary between a 1⁄2 and 11⁄4 cups, depending on cereal type. Check the product’s nutrition-facts label.
c Because eggs are high in cholesterol, limit egg yolk intake to no more than 4 per week; 2 egg whites have the same protein content as 1 oz of meat.
d Fat content changes serving amount for fats and oils. For example, 1 tbsp of regular salad dressing ⫽ 1 serving; 1 tbsp of low-fat dressing ⫽ 1⁄2 serving; 1 tbsp fat-free dressing ⫽ 0 servings.
PEDIATRICS Volume 128, Supplement 5, December 2011
S225
port, 2008”11 from the Department of
Health and Human Services, the expert panel recommends that activity
be vigorous on 3 days/week (www.
health.gov/paguidelines). In working
with children and families, the expert
panel suggested that moderate-tovigorous activity could be compared
with jogging or playing baseball and that
vigorous physical activity could be compared with running, playing singles tennis, or playing soccer. Similarly, reducing sedentary time is convincingly
associated with a favorable cardiovascular profile, and the expert panel agreed
with the AAP recommendation for limiting leisure screen time to ⬍2 hours/day.
should be safely applicable in childhood and adolescence, because behavioral interventions to alter smoking behaviors have little if any morbidity and
because morbidity with pharmacologic treatment is limited. Physicians
who care for children are well positioned to provide prevention and treatment interventions for their patients.
Youth interventions must target parents as well as children, because parental smoking is both a risk factor for
child smoking and provides secondhand smoke exposure to fetuses and
children. The evidence review assessed prevention and treatment interventions in each of these areas.
7. TOBACCO EXPOSURE
Conclusions and Grading of the
Evidence on Preventing Tobacco
Exposure
Tobacco dependence is responsible for
⬃4 million deaths worldwide annually,
and in utero exposure to tobacco products, involuntary tobacco smoke exposure (secondhand smoke), and tobacco
use directly impair health in fetuses, infants, children, and adolescents. On the
basis of an analysis of published causes
of death, tobacco use is the leading actual cause of death in the United States.
The evidence that cigarette use is harmful and addictive is unequivocal. In childhood, nicotine is highly addicting;
symptoms of tobacco dependence
have been found after brief intermittent use. Cigarette use among high
school students declined from 1997 to
2003. Rates were stable from 2003 to
2007 with ⬎20% of high school students reporting daily smoking. From a
public health standpoint, the need to
reduce tobacco exposure is compelling, and a role for pediatric health
care providers is essential.
A clinical practice guideline update
from the US Public Health Service published in May 200812 systematically reviewed almost 9000 publications and
concluded that smoking prevention
and cessation interventions are effective in adults. These same methods
S226
EXPERT PANEL
Among all the known risk factors for
CVD, the dichotomy between known benefits of risk elimination and the paucity
of evidence for effective interventions to
achieve risk reduction in pediatric care
provider settings is greatest for tobacco
exposure. The quality of the evidence regarding the harm of smoking and the
benefits of avoiding passive smoke exposure, smoking prevention, and smoking
cessation is uniformly grade A. That evidence grades in the recommendations
are less than grade A reflects the lack of
existing evidence on interventions that
impact smoking behaviors in specific pediatric age groups as opposed to the collective evidence.
● Good-quality interventions in pediatric
care settings to decrease children’s environmental smoke exposure have had
mixed results (grade B).
● Intervention studies to prevent
smoking initiation have had moderate success, although long-term results are limited (grade B).
● Practice-based interventions to achieve
smoking cessation in adolescents have
had moderate success with limited
long-term follow-up (grade B).
● School-based
smoking-prevention
programs have been moderately
successful with limited long-term
follow-up (grade B).
Although the evidence base for effective office-based approaches to tobacco interventions is moderate and
mixed, the evidence that cigarette use
is harmful and addictive is unequivocal. The need to reduce tobacco exposure is so compelling that a role for
pediatric health care providers is essential. The lack of harm associated
with such interventions and the importance of communicating the message
of risk associated with tobacco provides the rationale for “strongly recommend” despite the lack of conclusive evidence that office-based
interventions reliably reduce tobacco
initiation or smoking cessation. Physicians and nurses who care for children are well positioned to provide intervention to patients who smoke. The
expert panel feels that such providers
should routinely identify patients who
smoke by using the medical history
(Table 7-1). Patients should be explicitly informed about the addictive and
adverse health effects of tobacco use.
By using the 5 A’s (ask, advise, assess,
assist, and arrange), providers can assess readiness to quit and assist in
providing resources to support
smoking-cessation efforts. Information about telephone quit lines (eg,
1-800-QUIT-NOW), community cessation
programs, and pharmacotherapy
should also be made available.
As described, practice-based interventions to decrease environmental
smoke exposure have had mixed results. Nonetheless, the expert panel
believes that pediatric care providers
should identify parents and other
caregivers who smoke and explicitly
recommend that children not be exposed to tobacco smoke in the home,
in automobiles, or in any other space
where exposure can occur. For the
SUPPLEMENT ARTICLES
TABLE 6-1 Evidence-Based Activity Recommendations for Cardiovascular Health
Newborn to
12 mo
1 to 4 y
Parents should create an environment that promotes and models
physical activity and limits sedentary time
Supportive actions:
Discourage TV viewing altogether
Allow unlimited active playtime in safe, supportive environments
Limit sedentary time, especially TV/video
5 to 10 y
Supportive actions:
Limit total media time to no more than 1-2 hours of quality
programming per day
For children ⱕ2 y old, discourage TV viewing altogether
No TV in child’s bedroom
Encourage family activity at least once per week
Counsel routine activity for parents as role models for children
Moderate-to-vigorous physical activity every daya
Limit daily leisure screen time (TV/video/computer)
11 to 17 y
Supportive actions:
Prescribe moderate-to-vigorous activity 1 h/da with vigorousintensity physical activity 3 d/wkb
Limit total media time to no more than 1–2 h/d of quality
programming
No TV in child’s bedroom
Take activity and screen-time history from child once per year
Match physical activity recommendations with energy intake
Recommend appropriate safety equipment relative to each
sport
Support recommendations for daily physical education in
schools
Moderate-to-vigorous physical activity every daya
Limit leisure time TV/video/computer use
18 to 21 y
Supportive actions:
Encourage adolescents to aim for 1 h/d of moderate-to-vigorous
daily activitya with vigorous intense physical activityb 3 d/wk
Encourage no TV in bedroom
Limit total media time to no more than 1–2 h/d of quality
programming
Match activity recommendations with energy intake
Take activity and screen-time history from adolescent at health
supervision visits
Encourage involvement in year-round physical activities
Support continued family activity once per week and/or family
support of adolescent’s physical activity program
Endorse appropriate safety equipment relative to each sport
Moderate-to-vigorous physical activity every daya
Limit leisure time TV/video/computer
parent who smokes, information provided should include statements about
health benefits to the individual, child,
and/or fetus and referral to smokingcessation care providers.
Grade D
Recommend
Grade D
Recommend
Grade D
Recommend
8. HIGH BP
Grade A
Strongly recommend
Grade B
Strongly recommend
Grade A
Strongly recommend
Grade B
Strongly recommend
Grade A
Strongly recommend
Grade B
Strongly recommend
Supportive actions:
Support goal of 1 h/d of moderate-to-vigorous activity with
vigorous intense physical activity 3 d/wk
Recommend that combined leisure screen time not exceed 2 h/d
Activity and screen-time history at health supervision visits
Encourage involvement in year-round, lifelong physical activities
In 2004, an NHLBI task force published
“The Fourth Report on the Diagnosis,
Evaluation, and Treatment of High
Blood Pressure in Children and Adolescents.”13 This report included a complete review of the current evidence on
this subject and detailed recommendations for managing BP throughout
childhood. These recommendations
were used as the basis for these guidelines, considered complete until 2003
when the review for the report ended.
Therefore, this evidence review for BP
for these guidelines was limited to studies published between January 1, 2003,
and June 30, 2007, with the addition of
selected studies through June 30, 2008,
identified by the expert panel as having
met all the criteria for inclusion. Repeating the review performed by the task
force was not felt to be necessary, given
the short time since publication of that
report, or a judicious use of the resources available for development of
these guidelines. Recommendations regarding BP are all graded as expert opinion (grade D), because they are based on
the expert consensus conclusions of this
NHLBI task force.
Conclusions of the Evidence-Review
Update for High BP (2003–2008)
● The evidence review for the defined
time period resulted in no major
changes in the approach to BP evaluation and management.
● According to epidemiologic surveys
Grades reflect the findings of the evidence review; recommendation levels reflect the consensus opinion of the expert
panel; and supportive actions represent expert consensus suggestions from the expert panel provided to support
implementation of the recommendations (they are not graded).
a Examples of moderate-to-vigorous physical activities are jogging and playing baseball.
b Examples of vigorous physical activities are running, playing singles tennis, and playing soccer.
of children and adolescents over
the past 20 years, BP levels have
been increasing, and the prevalence
of hypertension and prehypertension are also increasing, explained
partially by the rise in obesity rates.
PEDIATRICS Volume 128, Supplement 5, December 2011
S227
TABLE 7-1 Evidence-Based Recommendations to Prevent Tobacco Exposure
Prenatal
Obtain smoking history from mothers; provide explicit smoking-cessation message before
and during pregnancy
Supportive actions:
Identify resources to support maternal smoking-cessation efforts.
Advocate for school and community-based smoke-free interventions
See “Perinatal Factors” section
Smoke-free home environment
0 to 4 y
Reinforce this message at every encounter, including urgent visits for respiratory problems
5 to 10 y
Supportive actions:
Provide information about health benefits of a smoke-free home to parents and children
Advocate for school- and community-based smoke-free interventions
Obtain smoke-exposure history from child, including personal history of tobacco use
11 to 21 y
Counsel patients strongly about not smoking, including providing explicit information about
the addictive and adverse health effects of smoking
Obtain personal smoking history at every nonurgent health encounter
Explicitly recommend against smoking
Provide specific smoking-cessation guidance
Grade A
Strongly recommend
Grade B
Strongly recommend
Grade C
Recommend
Grade C
Recommend
Grade C
Recommend
Grade B
Strongly recommend
Grade B
Strongly recommend
Grade B
Strongly recommend
Supportive actions:
Use 5 A questions to assess readiness to quit
Establish your health care practice as a resource for smoking cessation
Provide quit-line phone number
Identify community cessation resources
Provide information about pharmacotherapy for cessation
Advocate for school and community-based smoke-free interventions
Grades reflect the findings of the evidence review; recommendation levels reflect the consensus opinion of the expert panel; and supportive actions represent expert consensus
suggestions from the expert panel provided to support implementation of the recommendations (they are not graded).
● Prehypertension progresses to hy-
pertension at a rate of ⬃7% per
year; hypertension persists in almost one-third of boys and onefourth of girls on 2-year longitudinal
follow-up.
● Breastfeeding and supplementation
of formula with polyunsaturated
fatty acids in infancy are both associated with lower BP at follow-up.
● A DASH-style diet, which is rich in
fruits, vegetables, low-fat or fat-free
dairy products, whole grains, fish,
poultry, beans, seeds, and nuts and
lower in sweets and added sugars,
fats, and red meats than the typical
American diet, is associated with
lower BP. The CHILD-1 combined
with the DASH eating plan described
in “Diet and Nutrition” is an appropriate diet for children that meets
the DASH study and 2010 DGA nutrient goals.
S228
EXPERT PANEL
● Lower dietary sodium intake is as-
● In another study, transcendental
sociated with lower BP levels in infants, children, and adolescents.
meditation effectively lowered BP in
nonhypertensive adolescents.
● Losartan, amlodipine, felodipine, fosi-
nopril, lisinopril, metoprolol, and valsartan can be added to the list of medications that are tolerated over short
periods and can reduce BP in children
from ages 6 to 17 years but are predominantly effective in adolescents.
For black children, greater doses of
fosinopril might be needed for effective BP control. Medications are
shown in Table 8-5.
●In 1 study of small-for-gestationalage infants, a nutrient-enriched diet
that promoted rapid weight gain was
associated with higher BP on
follow-up in late childhood. This potential risk should be considered
when such diets are selected in the
clinical setting.
Recommendations
In “The Fourth Report on the Diagnosis,
Evaluation, and Treatment of High
Blood Pressure in Children and Adolescents,”13 an NHLBI task force provided
an algorithm and flow diagram to assist clinicians in identifying hypertension in children. For these guidelines,
the task force’s recommendations are
stratified here to provide an ageappropriate approach congruent with
other risk-factor recommendations in
other sections, and this is also reflected in a series of revised algorithms (Table 8-1 and Figs 8-1 and 8-2).
Conditions under which children
younger than 3 years should have BP
measured are shown in Table 8-2. The
BP norms for age, gender, and height
SUPPLEMENT ARTICLES
TABLE 8-1 Age-Specific Recommendations for BP Measurement and Diagnosis of
Hypertension
Birth to 3 y
3 to 11 y
12 to 17 y
18 to 21 y
No routine BP measurement
Measure BP if history (⫹) for neonatal complications, congenital heart disease, urinary/
renal abnormality, solid-organ transplant, malignancy, drug prescription, or
condition known to raise BP or increase intracranial pressure (Table 8-2)
If BP ⱖ90th percentile by oscillometry, confirm by auscultation ¡ If BP confirmed ⱖ90th
percentile, initiate evaluation for etiology and treatment per algorithm (Figure
8-2)
Annual BP measurement in all, interpreted for age/gender/height per Tables 8-3 and 8-4
If BP ⬍90th percentile, repeat in 1 y
If BP ⱖ90th percentile:
Repeat BP ⫻ 2 by auscultation
Average replicate measurements and reevaluate BP category (Fig 8-1)
If BP confirmed ⬎90th percentile, ⬍95th percentile ⫽ prehypertension (HTN):
Recommend weight management if indicated
Repeat BP in 6 mo
If BP ⱖ95th percentile, ⬍99th percentile ⫹ 5 mm Hg:
Repeat BP in 1–2 wk, average all BP measurements and reevaluate BP category (Fig
8-1)
If BP confirmed ⬎95th percentile, ⬍99th percentile ⫹ 5 mm Hg ⫽ stage 1 HTN:
Basic work-up per Fig 8-2
If BP ⱖ99th percentile ⫹ 5 mm Hg
Repeat BP by auscultation ⫻ 3 at that visit, average all BP measurements and
reevaluate BP category
If BP confirmed ⬎99th percentile ⫹ 5 mm Hg ⫽ stage 2 HTN:
Refer to pediatric HTN expert within 1 wk OR
Begin BP treatment and initiate basic work-up, per Fig 8-2
Annual BP measurement in all, interpreted for age/gender/height per Tables 8-3 and 8-4
If BP ⬍90th percentile, counsel on CHILD-1 diet, activity recommendations, and repeat BP
in 1 y
If BP ⱖ90th percentile or ⱖ120/80 mm Hg:
Repeat BP ⫻ 2 by auscultation
Average replicate measurements and reevaluate BP category (Fig 8-1)
If BP confirmed ⬎90th percentile, ⬍ 95th percentile or ⬎120/80 ⫽ pre-HTN:
CHILD-1 diet, activity recommendations, weight management if indicated
Repeat BP in 6 mo
If BP ⱖ95th percentile, ⬍99th percentile ⫹ 5 mm Hg
Repeat BP in 1–2 wk, average all BP measurements and reevaluate BP category (Fig
8-1)
If BP confirmed ⱖ95th percentile, ⬍99th percentile ⫹ 5 mm Hg ⫽ stage 1 HTN:
Basic workup per Fig 2
If BP ⱖ99th percentile ⫹ 5 mm Hg:
Repeat BP by auscultation ⫻ 3 at that visit, average all BP measurements and
reevaluate BP category
If BP confirmed ⬎99th percentile ⫹ 5 mm Hg ⫽ stage 2 HTN:
Refer to pediatric HTN expert within 1 wk OR
Begin BP treatment and initiate work-up per Fig 8-2
Measure BP at all health care visits
BP ⱖ120/80 to 139/89 ⫽ pre-HTN
BP ⱖ140/90 to 159/99 ⫽ stage 1 HTN
BP ⱖ160/100 ⫽ stage 2 HTN
BP recommendations are based on the NHLBI’s “The Fourth Report on the Diagnosis, Evaluation and Treatment of High Blood
Pressure in Children and Adolescents” with the evidence review updated from 2003. Recommendations are all graded as
expert opinion (grade D) because they are based on the expert consensus conclusions of the Fourth Report.
are shown in Tables 8-3 and 8-4 and
were taken directly from the NHLBI
task force’s report. Age-specific percentiles of BP measurements from
birth to 12 months are provided in the
“Report of the Fourth Task Force on
Blood Pressure Control in Children.”
For all age groups the assessment of
left ventricular mass by echocardiography is recommended as the best
method of assessing hypertensive target organ disease; this testing should
be performed for patients with stage 2
hypertension and those with persis-
tent stage 1 hypertension. Elevated left
ventricular mass might be useful in establishing the need for pharmacologic
treatment of hypertension. In Table 8-5,
the medications used to achieve BP
control in children and adolescents
are listed. At present, there are no data
to support the use of specific antihypertensive agents for specific age
groups.
9. LIPIDS AND LIPOPROTEINS
Since the last NHLBI guidelines for lipid
management in children and adolescents were published in 1992,1 both the
knowledge base surrounding dyslipidemia in childhood and the clinical picture have changed. A series of critical
observational studies have found a
clear correlation between lipoprotein
disorders and the onset and severity of
atherosclerosis in children, adolescents, and young adults. A major increase in the prevalence of obesity has
led to a much larger population of children with dyslipidemia. At the time of
the original guidelines, the focus was
almost exclusively on identification of
children with an elevated LDL cholesterol level. Since then, the predominant dyslipidemic pattern in childhood
is a combined pattern associated with
obesity, moderate-to-severe elevation
in triglyceride level, normal-to-mild
elevation in LDL cholesterol level,
and a reduced HDL cholesterol level.
Both dyslipidemic patterns have
been shown to be associated with initiation and progression of atherosclerotic lesions in children and adolescents as demonstrated by
pathology and imaging studies. Identification of children with dyslipidemias, which place them at increased risk for accelerated early
atherosclerosis, must include a comprehensive assessment of serum
lipid and lipoprotein levels.
The evidence review for lipids and lipoproteins addressed the association
PEDIATRICS Volume 128, Supplement 5, December 2011
S229
TABLE 8-2 Conditions Under Which Children <3 Years Old Should Have BP Measured
History of prematurity, very low birth weight, or other neonatal complication requiring intensive care
Congenital heart disease (repaired or unrepaired)
Recurrent urinary tract infections, hematuria, or proteinuria
Known renal disease or urologic malformations
Family history of congenital renal disease
Solid-organ transplant
Malignancy or bone marrow transplant
Treatment with drugs known to raise BP
Other systemic illnesses associated with hypertension (neurofibromatosis, tuberous sclerosis, etc)
Evidence of increased intracranial pressure
Reproduced with permission from High Blood Pressure Education Program Working Group on High Blood Pressure in
Children and Adolescents. Pediatrics. 2004;114(2 suppl 4th report):556.
between dyslipidemia and atherosclerosis in childhood, lipid assessment in
childhood and adolescence with tables
of normative results provided, the dyslipidemias, dietary treatment of dyslipidemia, and medication therapy.
Conclusions and Grading of the
Evidence Review for Lipid
Assessment in Childhood and
Adolescence
● Combined evidence from autopsy
studies, vascular studies, and cohort studies strongly indicates that
abnormal lipid levels in childhood
are associated with increased evidence of atherosclerosis (grade B).
● The evidence review supports the
concept that early identification and
control of dyslipidemia throughout
youth and into adulthood will substantially reduce clinical CVD risk
beginning in young adult life. Preliminary evidence in children with
heterozygous familial hypercholesterolemia with markedly elevated
LDL cholesterol levels indicates that
earlier treatment is associated with
reduced subclinical evidence of atherosclerosis (grade B).
● Multiple prospective screening co-
hort studies have demonstrated the
normal lipid and lipoprotein distributions in childhood, adolescence,
and young adult life (Tables 9-1 and
9-2) (grade B). Cohort studies have
also demonstrated significant
tracking of elevated lipid levels from
S230
EXPERT PANEL
childhood into adulthood. Lipid and
lipoprotein results in childhood are
predictive of future adult lipoprotein profiles; the strongest statistical correlation occurs between results in late childhood and in the
third and fourth decades of life
(grade B).
● TC and LDL cholesterol levels de-
crease as much as 10% to 20% or
more during puberty (grade B). On the
basis of this normal pattern of change
in lipid and lipoprotein levels with
growth and maturation, 10 years of
age (range: 9 –11 years) is a stable
time for lipid assessment in children
(grade D). For most children, this age
range will precede the onset of
puberty.
● Significant evidence exists to indicate
that using family history of premature
CVD or cholesterol disorders as the
primary factor in determining lipid
screening for children misses ⬃30%
to 60% of children with dyslipidemias,
and accurate and reliable measures
of family history are not available
(grade B). In the absence of a clinical
or historic marker, identification of
children with lipid disorders that predispose them to accelerated atherosclerosis requires universal lipid assessment (grade B).
● Non-HDL cholesterol level has been
identified as a significant predictor
of the presence of atherosclerosis,
as powerful as any other lipoprotein
cholesterol measure in children
and adolescents. For both children
and adults, non-HDL cholesterol
level seems to be more predictive of
persistent dyslipidemia and, therefore, atherosclerosis and future
events than TC, LDL cholesterol, or
HDL cholesterol levels alone. A major advantage of non-HDL cholesterol is that it can be accurately calculated in a nonfasting state and is
therefore practical to obtain in clinical practice. The expert panel felt
that non-HDL cholesterol should be
added as a screening tool for identification of a dyslipidemic state in
childhood (grade B).
● In terms of other lipid measure-
ments, (1) most but not all studies
have found that measurement of
apolipoprotein B and apolipoprotein A-1 for universal screening provides no additional advantage over
measuring non-HDL cholesterol, LDL
cholesterol, and HDL cholesterol levels, (2) measurement of lipoprotein(a) is useful in the assessment
of children with both hemorrhagic
and ischemic stroke, (3) in offspring
of a parent with premature CVD and
no other identifiable risk factors, elevations of apolipoprotein B, apolipoprotein A-1, and lipoprotein(a)
have been noted, and (4) measurement of lipoprotein subclasses and
their sizes by advanced lipoprotein
testing has not been found to have
sufficient clinical utility in children
at this time (grade B).
● Obesity is commonly associated
with a combined dyslipidemia pattern with mild elevation in TC and
LDL cholesterol levels, moderate-tosevere elevation in triglyceride
level, and a low HDL cholesterol
level. This is the most common dyslipidemic pattern seen in childhood,
and lipid assessment in overweight
and obese children identifies an important proportion of those with
SUPPLEMENT ARTICLES
TABLE 8-3 BP Norms for Boys by Age and Height Percentile
Age, BP %ile
y
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
5th
80
94
98
105
84
97
101
109
86
100
104
111
88
102
106
113
90
104
108
115
91
105
109
116
92
106
110
117
94
107
111
119
95
109
113
120
97
111
115
122
99
113
117
124
101
115
119
126
104
117
121
128
106
120
124
131
109
122
126
134
111
125
129
136
114
127
131
139
10th
81
95
99
106
85
99
102
110
87
101
105
112
89
103
107
114
91
105
109
116
92
106
110
117
94
107
111
118
95
109
112
120
96
110
114
121
98
112
116
123
100
114
118
125
102
116
120
127
105
118
122
130
107
121
125
132
110
124
127
135
112
126
130
137
115
128
132
140
SBP, mm Hg
DBP, mm Hg
Percentile of Height
Percentile of Height
25th
83
97
101
108
87
100
104
111
89
103
107
114
91
105
109
116
93
106
110
118
94
108
112
119
95
109
113
120
97
110
114
122
98
112
116
123
100
114
117
125
102
115
119
127
104
118
122
129
106
120
124
131
109
123
127
134
112
125
129
136
114
128
132
139
116
130
134
141
50th
85
99
103
110
88
102
106
113
91
105
109
116
93
107
111
118
95
108
112
120
96
110
114
121
97
111
115
122
99
112
116
123
100
114
118
125
102
115
119
127
104
117
121
129
106
120
123
131
108
122
126
133
111
125
128
136
113
127
131
138
116
130
134
141
118
132
136
143
significant
(grade B).
lipid
abnormalities
● Dyslipidemias can be acquired ge-
75th 90th 95th 5th 10th 25th 50th 75th 90th 95th
87
88
89 34
35
36
37
38
39
39
100 102 103 49
50
51
52
53
53
54
104 106 106 54
54
55
56
57
58
58
112 113 114 61
62
63
64
65
66
66
90
92
92 39
40
41
42
43
44
44
104 105 106 54
55
56
57
58
58
59
108 109 110 59
59
60
61
62
63
63
115 117 117 66
67
68
69
70
71
71
93
94
95 44
44
45
46
47
48
48
107 108 109 59
59
60
61
62
63
63
110 112 113 63
63
64
65
66
67
67
118 119 120 71
71
72
73
74
75
75
95
96
97 47
48
49
50
51
51
52
109 110 111 62
63
64
65
66
66
67
112 114 115 66
67
68
69
70
71
71
120 121 122 74
75
76
77
78
78
79
96
98
98 50
51
52
53
54
55
55
110 111 112 65
66
67
68
69
69
70
114 115 116 69
70
71
72
73
74
74
121 123 123 77
78
79
80
81
81
82
98
99 100 53
53
54
55
56
57
57
111 113 113 68
68
69
70
71
72
72
115 117 117 72
72
73
74
75
76
76
123 124 125 80
80
81
82
83
84
84
99 100 101 55
55
56
57
58
59
59
113 114 115 70
70
71
72
73
74
74
117 118 119 74
74
75
76
77
78
78
124 125 126 82
82
83
84
85
86
86
100 102 102 56
57
58
59
60
60
61
114 115 116 71
72
72
73
74
75
76
118 119 120 75
76
77
78
79
79
80
125 127 127 83
84
85
86
87
87
88
102 103 104 57
58
59
60
61
61
62
115 117 118 72
73
74
75
76
76
77
119 121 121 76
77
78
79
80
81
81
127 128 129 84
85
86
87
88
88
89
103 105 106 58
59
60
61
61
62
63
117 119 119 73
73
74
75
76
77
78
121 122 123 77
78
79
80
81
81
82
128 130 130 85
86
86
88
88
89
90
105 107 107 59
59
60
61
62
63
63
119 120 121 74
74
75
76
77
78
78
123 124 125 78
78
79
80
81
82
82
130 132 132 86
86
87
88
89
90
90
108 109 110 59
60
61
62
63
63
64
121 123 123 74
75
75
76
77
78
79
125 127 127 78
79
80
81
82
82
83
133 134 135 86
87
88
89
90
90
91
110 111 112 60
60
61
62
63
64
64
124 125 126 75
75
76
77
78
79
79
128 129 130 79
79
80
81
82
83
83
135 136 137 87
87
88
89
90
91
91
113 114 115 60
61
62
63
64
65
65
126 128 128 75
76
77
78
79
79
80
130 132 132 80
80
81
82
83
84
84
138 139 140 87
88
89
90
91
92
92
115 117 117 61
62
63
64
65
66
66
129 130 131 76
77
78
79
80
80
81
133 134 135 81
81
82
83
84
85
85
140 142 142 88
89
90
91
92
93
93
118 119 120 63
63
64
65
66
67
67
131 133 134 78
78
79
80
81
82
82
135 137 137 82
83
83
84
85
86
87
143 144 145 90
90
91
92
93
94
94
120 121 122 65
66
66
67
68
69
70
134 135 136 80
80
81
82
83
84
84
138 139 140 84
85
86
87
87
88
89
145 146 147 92
93
93
94
95
96
97
The 90th percentile is 1.28 SD, the 95th percentile is 1.645 SD, and the 99th percentile is 2.326 SD over the mean.
Reproduced with permission from High Blood Pressure Education Program Working Group on High Blood Pressure in
Children and Adolescents. Pediatrics. 2004;114(2 suppl 4th report):558.
netically but also secondary to specific conditions such as DM, nephrotic syndrome, chronic renal
disease, postorthotopic heart transplant, history of Kawasaki disease
with persistent coronary involvement, chronic inflammatory disease, hypothyroidism, and other
causes, as outlined in Table 9-3.
There is impressive evidence for
accelerated atherosclerosis both
clinically and as assessed with
noninvasive methods in some of
these conditions, which have been
designated accordingly as special
risk diagnoses for accelerated
atherosclerosis
(Table
9-7);
management of these conditions
is described in “DM and Other
Conditions Predisposing to the Development of Accelerated Atherosclerosis.” Lipid evaluation for
these patients contributes to risk
assessment and identifies an important proportion of those with
dyslipidemia (grade B).
● The complete phenotypic expres-
sion of some inherited disorders
such as familial combined hyperlipidemia may be delayed until adulthood. Therefore, evaluation of
children and adolescents from highrisk families with familial combined
hyperlipidemia (Table 9-4) should
begin in childhood and continue
through adulthood (per NCEP adult
treatment guidelines) and will lead
to early detection of those with abnormalities (grade B).
Age-specific recommendations for
lipid assessment are outlined in Table
9-5. Specific management for children
with identified dyslipidemia is outlined
in the algorithms in Figs 9-1 and 9-2.
Definitions of the risk factors and special risk conditions for use with the
recommendations and in the algo-
PEDIATRICS Volume 128, Supplement 5, December 2011
S231
FIGURE 8-1
BP measurement and categorization. HT indicates height; WT, weight; HTN, hypertension; %ile, percentile. a See Table 8-2; b see “Nutrition and Diet”Table
5-1; c see “Physical Activity”; c see “Overweight and Obesity.” Adapted from High Blood Pressure Education Program Working Group on High Blood Pressure
in Children and Adolescents. Pediatrics. 2004;114(2 suppl 4th report):555–576.
rithms appear in Tables 9-6 and 9-7.
The first step proposed for management of children with identified lipid
abnormalities is a focused intervention on diet and physical activity.
Conclusions and Grading of the
Evidence Review for Dietary
Management of Dyslipidemia
● A diet with total fat at 25% to 30%
of calories, saturated fat at ⬍10%
of calories, and cholesterol intake
at ⬍300 mg/day, as recommended
by the original NCEP Pediatric
Panel,1 has been shown to safely
and effectively reduce the levels of
TC and LDL cholesterol in healthy
children (grade A). There is some
evidence that this is also the case
when the diet begins in infancy
and is sustained throughout child-
S232
EXPERT PANEL
hood and into adolescence (grade
B). The CHILD-1, described in “Nutrition and Diet,” has this
composition.
● In children with identified hyper-
cholesterolemia and an elevated
LDL cholesterol level, a more stringent diet with saturated fat at
ⱕ7% of calories and dietary cholesterol limited to 200 mg/day has
been shown to be safe and modestly effective in lowering the LDL
cholesterol level (grade A) (CHILD2–LDL; Table 9-8).
● The use of dietary adjuncts such
as plant sterol or stanol esters up
to 20 g/day can safely enhance LDL
cholesterol–lowering effects shortterm in children with familial hypercholesterolemia (grade A).
However, long-term studies on the
safety and effectiveness of plant
sterol and stanol esters have not
been completed. Their use, therefore, is usually reserved for children with primary elevations of
their LDL cholesterol level who do
not achieve LDL cholesterol goals
with dietary treatment alone. Such
an approach might lower the LDL
cholesterol level sufficiently to
avoid the necessity of drug treatment. Food products that contain
plant stanol esters, such as some
margarines, are marketed directly to the general public. In 2
short-term trials, they have been
shown to be safe and have minimal LDL-lowering effects in
healthy children (grade B).
SUPPLEMENT ARTICLES
FIGURE 8-2
BP management according to category. HTN indicates hypertension; CV, cardiovascular; Hx, history; PEx, physical examination; CBC, complete blood
count; U/A, urinalysis; U/S, ultrasound; Ped, pediatric; LVH, left ventricular hypertrophy; Q, every; Rx, prescription; 2°, secondary; W/U, workup; TOD, target
organ damage; s/p, status post; CKD, chronic kidney disease; %ile, percentile. a Workup for target organ damage/left ventricular hypertrophy if obese or
positive for other cardiovascular risk factors; b see “Nutrition and Diet”; c see “Physical Activity”; d see “Overweight and Obesity.” Adapted from High Blood
Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. Pediatrics. 2004;114(2 suppl 4th report):555–576.
● Evidence for the use of other dietary
supplements is insufficient for any
recommendation (no grade).
(shown in Table 9-8) is recommended as the primary diet therapy
in this setting.
● In children with an elevated triglyc-
● A behavioral approach that engages
eride level, reduction of simple carbohydrate intake and weight loss
are associated with decreased triglyceride levels (grade B). Reduction of simple carbohydrate intake
needs to be associated with increased intake of complex carbohydrates and reduced saturated-fat
intake. When triglyceride elevation
is associated with obesity, decreased calorie intake and increased activity levels are of paramount importance. The CHILD-2–TG
the child and family delivered by a
registered dietitian has been shown
to be the most consistently effective
approach for achieving dietary
change (grade B).
The approach to management of dyslipidemias is staged, as in the original
NCEP Pediatric Panel recommendations.1 For all children with identified
dyslipidemia in whom the response
to a low-fat/low-saturated-fat/lowcholesterol diet has not been evalu-
ated, the CHILD-1 (described in “Nutrition and Diet”) is recommended as the
first step; implementation should be
guided by a registered dietitian.
For obese children with identified
dyslipidemia, additional age- and BMIspecific
recommendations
that
address calorie restriction and increased activity appear in “Overweight
and Obesity.” If, after a 3-month trial of
the CHILD-1/lifestyle management,
fasting-lipid-profile (FLP) findings exceed the therapeutic goals listed in Tables 9-1 and 9-2, then the lipid
parameter-specific diet changes outlined in Table 9-8 are recommended.
Dyslipidemia management is also out-
PEDIATRICS Volume 128, Supplement 5, December 2011
S233
TABLE 8-4 BP Norms for Girls by Age and Height Percentile
Age, BP %ile
y
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
50th
90th
95th
99th
SBP, mm Hg
DBP, mm Hg
Percentile of Height
Percentile of Height
5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th
83
84
85
86
88
89
90 38 39
39
40
41
41
42
97
97
98 100 101 102 103 52 53
53
54
55
55
56
100 101 102 104 105 106 107 56 57
57
58
59
59
60
108 108 109 111 112 113 114 64 64
65
65
66
67
67
85
85
87
88
89
91
91 43 44
44
45
46
46
47
98
99 100 101 103 104 105 57 58
58
59
60
61
61
102 103 104 105 107 108 109 61 62
62
63
64
65
65
109 110 111 112 114 115 116 69 69
70
70
71
72
72
86
87
88
89
91
92
93 47 48
48
49
50
50
51
100 100 102 103 104 106 106 61 62
62
63
64
64
65
104 104 105 107 108 109 110 65 66
66
67
68
68
69
111 111 113 114 115 116 117 73 73
74
74
75
76
76
88
88
90
91
92
94
94 50 50
51
52
52
53
54
101 102 103 104 106 107 108 64 64
65
66
67
67
68
105 106 107 108 110 111 112 68 68
69
70
71
71
72
112 113 114 115 117 118 119 76 76
76
77
78
79
79
89
90
91
93
94
95
96 52 53
53
54
55
55
56
103 103 105 106 107 109 109 66 67
67
68
69
69
70
107 107 108 110 111 112 113 70 71
71
72
73
73
74
114 114 116 117 118 120 120 78 78
79
79
80
81
81
91
92
93
94
96
97
98 54 54
55
56
56
57
58
104 105 106 108 109 110 111 68 68
69
70
70
71
72
108 109 110 111 113 114 115 72 72
73
74
74
75
76
115 116 117 119 120 121 122 80 80
80
81
82
83
83
93
93
95
96
97
99
99 55 56
56
57
58
58
59
106 107 108 109 111 112 113 69 70
70
71
72
72
73
110 111 112 113 115 116 116 73 74
74
75
76
76
77
117 118 119 120 122 123 124 81 81
82
82
83
84
84
95
95
96
98
99 100 101 57 57
57
58
59
60
60
108 109 110 111 113 114 114 71 71
71
72
73
74
74
112 112 114 115 116 118 118 75 75
75
76
77
78
78
119 120 121 122 123 125 125 82 82
83
83
84
85
86
96
97
98 100 101 102 103 58 58
58
59
60
61
61
110 110 112 113 114 116 116 72 72
72
73
74
75
75
114 114 115 117 118 119 120 76 76
76
77
78
79
79
121 121 123 124 125 127 127 83 83
84
84
85
86
87
98
99 100 102 103 104 105 59 59
59
60
61
62
62
112 112 114 115 116 118 118 73 73
73
74
75
76
76
116 116 117 119 120 121 122 77 77
77
78
79
80
80
123 123 125 126 127 129 129 84 84
85
86
86
87
88
100 101 102 103 105 106 107 60 60
60
61
62
63
63
114 114 116 117 118 119 120 74 74
74
75
76
77
77
118 118 119 121 122 123 124 78 78
78
79
80
81
81
125 125 126 128 129 130 131 85 85
86
87
87
88
89
102 103 104 105 107 108 109 61 61
61
62
63
64
64
116 116 117 119 120 121 122 75 75
75
76
77
78
78
119 120 121 123 124 125 126 79 79
79
80
81
82
82
127 127 128 130 131 132 133 86 86
87
88
88
89
90
104 105 106 107 109 110 110 62 62
62
63
64
65
65
117 118 119 121 122 123 124 76 76
76
77
78
79
79
121 122 123 124 126 127 128 80 80
80
81
82
83
83
128 129 130 132 133 134 135 87 87
88
89
89
90
91
106 106 107 109 110 111 112 63 63
63
64
65
66
66
119 120 121 122 124 125 125 77 77
77
78
79
80
80
123 123 125 126 127 129 129 81 81
81
82
83
84
84
130 131 132 133 135 136 136 88 88
89
90
90
91
92
107 108 109 110 111 113 113 64 64
64
65
66
67
67
120 121 122 123 125 126 127 78 78
78
79
80
81
81
124 125 126 127 129 130 131 82 82
82
83
84
85
85
131 132 133 134 136 137 138 89 89
90
91
91
92
93
108 108 110 111 112 114 114 64 64
65
66
66
67
68
121 122 123 124 126 127 128 78 78
79
80
81
81
82
125 126 127 128 130 131 132 82 82
83
84
85
85
86
132 133 134 135 137 138 139 90 90
90
91
92
93
93
108 109 110 111 113 114 115 64 65
65
66
67
67
68
122 122 123 125 126 127 128 78 79
79
80
81
81
82
125 126 127 129 130 131 132 82 83
83
84
85
85
86
133 133 134 136 137 138 139 90 90
91
91
92
93
93
The 90th percentile is 1.28 SD, the 95th percentile is 1.645 SD, and the 99th percentile is 2.326 SD over the mean.
Reproduced with permission from High Blood Pressure Education Program Working Group on High Blood Pressure in
Children and Adolescents. Pediatrics. 2004;114(2 suppl 4th report):559.
S234
EXPERT PANEL
lined in the algorithms in Figs 9-1 and
9-2.
Conclusions and Grading of the
Evidence Review for Use of
Medication to Treat Dyslipidemia
When medication is recommended,
it should always be in the context
of the complete cardiovascular
risk profile of the patient and in
consultation with the patient and
the family. Note that, in the following section, values given are in mg/
dL; to convert to SI units, divide the
results for TC, LDL cholesterol, HDL
cholesterol, and non-HDL cholesterol
by 38.6; for triglycerides, divide by
88.6.
● Decisions regarding the need for
medication therapy should be
based on the average of results
from at least 2 FLPs obtained at
least 2 weeks but no more than 3
months apart (grade C) (Fig 9-1).
● The cut points used to define the
level at which drug therapy should
be considered from the 1992 NCEP
pediatric guidelines1 have been
used as the basis for multiple drug
safety and efficacy trials in dyslipidemic children (grade B):
●
LDL cholesterol ⱖ 190 mg/dL after a 6-month trial of lifestyle
management (CHILD-1 ¡ CHILD2–LDL) for children aged 10 years
or older.
●
LDL cholesterol 160 to 189
mg/dL after a 6-month trial of
lifestyle/diet
management
(CHILD-1 ¡ CHILD-2–LDL) in a
child aged 10 years or older
with a positive family history of
premature CVD/events in firstdegree relatives (Table 9-6) or
at least 1 high-level risk factor
or risk condition or at least 2
moderate-level risk factors or
risk conditions (Tables 9-6, 9-7,
and 9-12; Fig 9-1).
SUPPLEMENT ARTICLES
TABLE 8-5 Antihypertensive Medications With Pediatric Experience
Class
ACE inhibitors
ARBs
Drug
Initial Dosea
Maximal Dose
Dosing
Interval
Evidenceb FDAc
Benazepril
0.2 mg/kg per d up to
10 mg/d
0.6 mg/kg per d up QD
to 40 mg/d
RCT
Yes
Captopril
0.3–0.5 mg/kg per
dose (⬎12 mo)
6 mg/kg per d
TID
RCT, CS
No
Fosinoprile
Children ⬎50 kg:
5–10 mg/d
40 mg/d
QD
RCT
Yes
Lisinoprile
0.07 mg/kg per d up
to 5 mg/d
0.6 mg/kg per d up QD
to 40 mg/d
RCT
Yes
Quinapril
5–10 mg/d
80 mg/d
QD
RCT, EO
No
Irbesartan
6–12 y: 75–150 mg/d;
ⱖ13 y: 150–300
mg/d
0.7 mg/kg per d up to
50 mg/d
300 mg/d
QD
CS
Yes
RCT
Yes
RCT
No
Losartane
1.4 mg/kg per d up QD–BID
to 100 mg/d
Commentsd
1. All ACE inhibitors are contraindicated
in pregnancy; women of childbearing
age should use reliable contraception
2. Check serum potassium and creatinine
periodically to monitor for
hyperkalemia and azotemia
3. Cough and angioedema are reportedly
less common with newer members of
this class than with captopril
4. Benazepril, enalapril, and lisinopril
labels contain information on the
preparation of a suspension; captopril
may also be compounded into a
suspension
5. FDA approval for ACE inhibitors with
pediatric labeling is limited to children
ⱖ6 y of age and to children with
creatinine clearance rate of ⱖ30 mL/
min per 1.73 m2
6. Initial dose of fosinopril of 0.1 mg/kg
per d may be effective, although black
patients might require a higher dose
1. All ARBs are contraindicated in
pregnancy; women of childbearing age
should use reliable contraception
2. Check serum potassium and creatinine
levels periodically to monitor for
hyperkalemia and azotemia
3. Losartan label contains information on
the preparation of a suspension
4. FDA approval for ARBs is limited to
children ⱖ6 y of age and to children
with creatinine clearance rate of ⱖ30
mL/min per 1.73 m2
Valsartane
5–10 mg/d; 0.4 mg/kg 40–80 mg/d; 3.4
per d
mg/kg per d
␣- and
␤-antagonist
Labetalol
1–3 mg/kg per d
10–12 mg/kg per d BID
up to 1200 mg/d
CS, EO
No
1. Asthma and overt heart failure are
relative contraindications
2. Heart rate is dose-limiting
3. May impair athletic performance in
athletes
4. Should not be used in insulindependent diabetic patients
␤-antagonists
Atenolol
0.5–1 mg/kg per d
2 mg/kg per d up
to 100 mg/d
QD–BID
CS
No
Bisoprolol/
hydrochlorothiazide
Metoprolole
2.5–6.25 mg/d
10/6.25 mg/d
QD
RCT
No
1. Noncardioselective agents
(propranolol) are contraindicated in
asthma and heart failure
2. Heart rate is dose-limiting
Children ⬎6 y: 1 mg/
kg per d (12.5–50
mg/d)
1–2 mg/kg per d
2 mg/kg per d up
to 200 mg/d
BID
CS
Yesf 3. May impair athletic performance in
athletes
4 mg/kg per d up
to 640 mg/d
BID–TID
RCT, EO
Yes
4. Should not be used in insulindependent diabetic patients
5. A sustained-release, once-daily
formulation of propranolol is available
Amlodipinee
Children 6–17 y: 2.5
mg/d
5 mg/d
QD
RCT
Yes
Felodipine
2.5 mg/d
10 mg/d
QD
RCT, EO
No
1. Amlodipine and isradipine can be
compounded into stable
extemporaneous suspensions
2. Felodipine and extended-release
nifedipine tablets must be swallowed
whole
Propranolol
Calcium-channel
blockers
QD
PEDIATRICS Volume 128, Supplement 5, December 2011
S235
TABLE 8-5 Continued
Class
Central ␣-agonist
Drug
Initial Dosea
Isradipine
0.15–0.2 mg/kg per d
Extended-release
nifedipine
0.25–0.5 mg/kg per d
Clonidine
Children ⱖ12 y: 0.2
mg/d
Dosing Evidenceb FDAc
Commentsd
Interval
0.8 mg/kg per d up TID–QID CS, EO
No 3. Isradipine is available in both
to 20 mg/d
immediate- and sustained-release
formulations; sustained release form
is dosed QD or BID
3 mg/kg per d up
QD–BID CS, EO
No 4. May cause tachycardia
5. Doses up to 10 mg of amlodipine have
to 120 mg/d
been evaluated in children
6. Contraindicated for children ⬍1 y of
age
Maximal Dose
2.4 mg/d
BID
EO
Yes
1. May cause dry mouth and/or sedation
2. Transdermal preparation is available
3. Sudden cessation of therapy can lead
to severe rebound hypertension
Diuretics
Peripheral
␣-antagonists
Vasodilators
Hydrochlorothiazide
1 mg/kg per d
3 mg/kg per d up
to 50 mg/d
QD
EO
Yes
Chlorthalidone
0.3 mg/kg per d
2 mg/kg per d up
to 50 mg/d
QD
EO
No
Furosemide
0.5–2.0 mg/kg per
dose
6 mg/kg per d
QD–BID
EO
No
Spironolactone
1 mg/kg per d
3.3 mg/kg per d up QD–BID
to 100 mg/d
EO
No
Triamterene
1–2 mg/kg per d
3–4 mg/kg per d
up to 300 mg/d
BID
EO
No
Amiloride
0.4–0.625 mg/kg per
d
20 mg/d
QD
EO
No
Doxazosin
1 mg/d
4 mg/d
QD
EO
No
Prazosin
0.5 mg/kg per d
TID
EO
No
Terazosin
0.05–0.1 mg/kg per
day
1 mg/d
20 mg/d
QD
EO
No
Hydralazine
0.75 mg/kg per d
EO
Yes
Minoxidil
Children ⬍12 y: 0.2
mg/kg per d;
children ⬎12 y: 5
mg/d
7.5 mg/kg per d up QID
to 200 mg/d
Children ⬍12 y: 50 QD–TID
mg/d; children
ⱖ12 y: 100
mg/d
CS, EO
Yes
1. All patients treated with diuretics
should have their electrolytes
monitored shortly after initiating
therapy and periodically thereafter
2. Useful as add-on therapy in patients
being treated with drugs from other
drug classes
3. Potassium-sparing diuretics
(spironolactone, triamterene,
amiloride) may cause severe
hyperkalemia, especially if given with
an ACE inhibitor or ARB
4. Furosemide is labeled only for
treatment of edema but may be useful
as add-on therapy in children with
resistant hypertension, particularly in
children with renal disease
5. Chlorthalidone may precipitate
azotemia in patients with renal
diseases and should be used with
caution in those with severe renal
impairment
1. May cause first-dose hypotension
1. Tachycardia and fluid retention are
common adverse effects
2. Hydralazine can cause a lupus-like
syndrome in slow acetylators
3. Prolonged use of minoxidil can cause
hypertrichosis
4. Minoxidil is usually reserved for
patients with hypertension that is
resistant to multiple drugs
ACE indicates angiotensin-converting enzyme; QD, every day; BID, 2 times daily; TID, 3 times daily; QID, 4 times daily; CS, case series; EO, expert opinion; ARB, angiotensin-receptor blocker.
a The maximal recommended adult dose should not be exceeded in routine clinical practice.
b Level of evidence on which recommendations are based.
c FDA-approved pediatric labeling information is available for treatment of hypertension. Recommended doses for agents with FDA-approved pediatric labels contained in this table are the
doses contained in the approved labels. Even when pediatric labeling information is not available, the FDA-approved label should be consulted for additional safety information.
d Comments apply to all members of each drug class except where otherwise stated.
e Indicates drug added since “The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents” (2004).
f Study did not reach the primary end point (dose response for reduction in systolic BP). Some prespecified secondary end points demonstrated effectiveness.
Adapted from High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. Pediatrics. 2004;114(2 suppl 4th report):555–576.
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EXPERT PANEL
SUPPLEMENT ARTICLES
TABLE 9-1 Acceptable, Borderline-High, and High Plasma Lipid, Lipoprotein, and
TABLE 9-3 Causes of Secondary
Apolipoprotein Concentrations for Children and Adolescents
a
Dyslipidemia
a
Category
Low, mg/dL
Acceptable, mg/dL
Borderline-High, mg/dL
High, mg/dL
TC
LDL cholesterol
Non-HDL cholesterol
Apolipoprotein B
Triglycerides
0–9 y
10–19 y
HDL cholesterol
Apolipoprotein A-1
—
—
—
—
⬍170
⬍110
⬍120
⬍90
170–199
110–129
120–144
90–109
ⱖ200
ⱖ130
ⱖ145
ⱖ110
—
—
⬍40
⬍115
⬍75
⬍90
⬎45
⬎120
75–99
90–129
40–45
115–120
ⱖ100
ⱖ130
—
—
Values for plasma lipid and lipoprotein levels are from the NCEP Expert Panel on Cholesterol Levels in Children. Non-HDL
cholesterol values from the Bogalusa Heart Study are equivalent to the NCEP Pediatric Panel cut points for LDL cholesterol.
Values for plasma apolipoprotein B and apolipoprotein A-1 are from the National Health and Nutrition Examination Survey
III. Note that values shown are in mg/dL; to convert to SI units, divide the results for TC, LDL cholesterol, HDL cholesterol, and
non-HDL cholesterol by 38.6; for triglycerides, divide by 88.6.
a Low cut points for HDL cholesterol and apolipoprotein A-1 represent approximately the 10th percentile. The cut points for
high and borderline-high represent approximately the 95th and 75th percentiles, respectively.
TABLE 9-2 Recommended Cut Points for Lipid and Lipoprotein Levels in Young Adults
Category
Low, mg/dL
Borderline-Low,
mg/dL
Acceptable,
mg/dL
Borderline-High,
mg/dL
High, mg/dL
TC
LDL cholesterol
Non-HDL cholesterol
Triglycerides
HDL cholesterol
—
—
—
—
⬍40
—
—
—
—
40–44
⬍190
⬍120
⬍150
⬍115
⬎45
190–224
120–159
150–189
115–149
—
ⱖ225
ⱖ160
ⱖ190
ⱖ150
—
Values provided are from the Lipid Research Clinics Prevalence Study. The cut points for TC, LDL cholesterol, and non-HDL
cholesterol represent the 95th percentile for 20- to 24-year-old subjects and are not identical with the cut points used in the
most recent NHLBI adult guidelines, Adult Treatment Panel III (“Third Report of the Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults”), which are derived from combined data on adults of all ages. The age-specific
cut points given here are provided for pediatric care providers to use in managing this young adult age group. For TC, LDL
cholesterol, and non-HDL cholesterol, borderline-high values are between the 75th and 94th percentiles, whereas acceptable value are at the ⬍75th percentile. The high triglyceride cut point represents approximately the 90th percentile;
borderline-high values are between the 75th and 89th percentiles, and acceptable values are at the ⬍75th percentile. The
low HDL cholesterol cut point represents approximately the 25th percentile; borderline-low values are between the 26th and
50th percentiles, and acceptable values are at the ⬎50th percentile.
●
●
LDL cholesterol 130 to 190 mg/dL in
a child aged 10 years or older with
a negative family history of premature CVD in first-degree relatives
and no high- or moderate-level risk
factor or risk condition: management should continue to focus on
lifestyle changes (CHILD-1 ¡ CHILD2–LDL) based on lipid-profile findings (Fig 9-1) plus weight management if the BMI is at the ⱖ85th
percentile.
The goal of LDL-lowering therapy
in childhood and adolescence is
to decrease the LDL cholesterol
level to the ⬍95th percentile
(ⱕ130 mg/dL).
● Children with homozygous familial
hypercholesterolemia and extremely
elevated LDL cholesterol levels (⬎500
mg/dL) have undergone effective LDLlowering therapy with biweekly LDL
apheresis under the care of lipid specialists in academic medical centers
(grade C).
Exogenous
Alcohol
Drug therapy: corticosteroids
Isoretinoin
␤-blockers
Some oral contraceptives
Select chemotherapeutic agents
Select antiretroviral agents
Endocrine/metabolic
Hypothyroidism/hypopituitarism
T1DM and T2DM
Pregnancy
Polycystic ovary syndrome
Lipodystrophy
Acute intermittent porphyria
Renal
Chronic renal disease
Hemolytic uremic syndrome
Nephrotic syndrome
Infectious
Acute viral/bacterial infectiona
HIV
Hepatitis
Hepatic
Obstructive liver disease/cholestatic conditions
Biliary cirrhosis
Alagille syndrome
Inflammatory disease
Systemic lupus erythematosis
Juvenile rheumatoid arthritis
Storage disease
Glycogen-storage disease
Gaucher disease
Cystine-storage disease
Juvenile Tay-Sachs disease
Niemann-Pick disease
Other
Kawasaki disease
Anorexia nervosa
Post–solid organ transplantation
Childhood cancer survivor
Progeria
Idiopathic hypercalcemia
Klinefelter syndrome
Werner syndrome
a
Delay measurement until ⱖ3 weeks after infection.
● Multiple cohort studies have found
that the benefits of LDL-lowering
therapy in children at high risk for
accelerated atherosclerosis (such
as those with chronic kidney disease, T1DM or T2DM, Kawasaki disease with coronary aneurysms,
or post– cardiac transplantation)
should be considered for initiation
of medication therapy (grade C)
(see “DM and Other Conditions Predisposing to the Development of Accelerated Atherosclerosis”).
● Bile acid sequestrants are medica-
tions that bind bile salts within the
intestinal lumen and prevent their
enterohepatic reuptake in the terminal ileum, which results in a depletion of bile salts in the liver and
signals for increased production.
Because bile salts are synthesized
from intracellular cholesterol in the
liver, the intracellular pool of cholesterol becomes depleted, which
signals increased production of LDL
PEDIATRICS Volume 128, Supplement 5, December 2011
S237
TABLE 9-4 Summary of Major Lipid Disorders in Children and Adolescents
Primary Lipid Disorders
Familial hypercholesterolemia
Homozygous
Heterozygous
Familial defective apolipoprotein B
Familial combined hyperlipidemiaa
Type IIa
Type IV
Type IIb
Types IIb and IV
Polygenic hypercholesterolemia
Familial hypertriglyceridemia (200–1000 mg/dL)
Severe hypertriglyceridemia (ⱖ1000 mg/dL)
Familial hypoalphalipoproteinemia
Dysbetalipoproteinemia (TC: 250–500 mg/dL;
triglycerides: 250–600 mg/dL)
Lipid/Lipoprotein Abnormality
11 LDL cholesterol
1 LDL cholesterola
1 LDL cholesterol
1 LDL cholesterol
1 VLDL cholesterol, 1 triglycerides
1 LDL cholesterol, 1 VLDL cholesterol, 1
triglycerides
2 HDL cholesterol (often)
1 LDL cholesterol
1 VLDL cholesterol, 1 triglycerides
1 chylomicrons, 1 VLDL cholesterol, 11
triglycerides
2 HDL cholesterol
1 IDL cholesterol, 1 chylomicron remnants
1 indicates increased; 2, decreased; IDL indicates intermediate-density lipoprotein; VLDL, very low density lipoprotein.
a These are the 2 lipid and lipoprotein disorders seen most frequently in childhood and adolescence; familial combined
hyperlipidemia most often manifests with obesity.
receptors and increased clearance
of circulating LDL cholesterol to replenish the intracellular cholesterol
pool for increased production of
bile salts. Studies of bile acid sequestrants in children and adolescents aged 6 to 18 years with LDL
cholesterol levels from 131 to 190
mg/dL have resulted in TC reduction
of 7% to 17% and reduction of LDL
cholesterol of 10% to 20%, sometimes with a modest elevation in triglyceride level. Bile acid sequestrants commonly cause adverse
gastrointestinal effects that can significantly affect compliance. However, they are safe and moderately
effective (grade A).
familial hypercholesterolemia (defined as elevated LDL cholesterol in
the child in conjunction with a family
history of elevated LDL cholesterol
and/or atherosclerosis or CAD) when
used from 8 weeks to 2 years for children aged 8 to 18 years. The lower LDL
cholesterol level for eligibility into the
statin trials was ⱖ190 or ⱖ160
mg/dL with ⱖ2 additional risk factors
after a trial period on diet. Trial subjects were monitored carefully
throughout treatment; adverse effects on growth, development, or sexual maturation were not seen, and
adverse-event profiles and efficacy
were similar to those in studies of
adults (grade A).
● Statin medications inhibit hydroxy-
● Adverse effects from statins are
methylglutaryl coenzyme A reductase, which is a rate-limiting enzyme
in the endogenous cholesterolsynthesis pathway. This inhibition results in a decrease in the intracellular
pool of cholesterol, which signals upregulation of LDL receptors and increased clearance of circulating LDL
cholesterol. As a group, statins have
been shown to reduce LDL cholesterol
in children and adolescents with
marked LDL cholesterol elevation or
rare at standard doses but include
myopathy and hepatic enzyme elevation. In a meta-analysis of statin use in
children, evidence of hepatic enzyme
elevation and muscle toxicity did not
differ between the statin and placebo
groups. Routine monitoring of hepatic
enzymes and clinical assessment for
muscle toxicity are strongly recommended for children and adolescents
on statin therapy (Table 9-12). The risk
of adverse events increases with use
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EXPERT PANEL
of higher doses and interacting
drugs; the latter occurs primarily
with drugs that are metabolized by
the cytochrome P-450 system, which
is the primary mode of metabolism
for the majority of statins. Drugs that
potentially interact with statins include fibrates, azole antifungal
agents, macrolide antibiotics, antiarrhythmic agents, and protease inhibitors (grade A).
● Bile acid– binding sequestrants may
be used in combination with a statin
for patients who fail to meet LDL cholesterol target levels with either medication alone. One pediatric study assessed this combination and found no
increase in adverse effects. The efficacy of the 2 agents together seems to
be additive (grade B).
● There is limited published experience
in children of use of niacin and fibrates, which have been useful in
treating adult patients with combined
dyslipidemias. Efficacy and safety
data are limited, and no data are available regarding newer formulations. In
adults, cholesterol absorption inhibitors have been advocated as an adjunct to statin therapy for patients
who do not reach LDL cholesterol
therapeutic targets. Because their action is independent of and complementary to that of statins, the LDL cholesterol–lowering effect is additive.
No pediatric studies of monotherapy
with cholesterol absorption inhibitors
had been published during the time
period for this evidence review. The
use of niacin, fibrates, and cholesterol
absorption inhibitors should be instituted only in consultation with a lipid
specialist (grade C).
● Medication therapy is rarely needed
for children with elevated triglyceride levels that respond well to
weight loss and lifestyle changes
(grade B) (Fig 9-2; Table 9-8). When
triglyceride levels exceed 500 mg/
dL, patients are at risk for pancre-
SUPPLEMENT ARTICLES
TABLE 9-5 Evidence-Based Recommendations for Lipid Assessment
Birth to 2 y
No lipid screening
2 to 8 y
No routine lipid screening
Grade C
Recommend
Grade B
Recommend
Measure fasting lipid profile twice,a average results if:
Parent, grandparent, aunt/uncle, or sibling with
MI, angina, stroke, CABG/stent/angioplasty at ⬍55 y in males, ⬍65 y in females
Parent with TC ⱖ 240 mg/dL or known dyslipidemia
Parent with TC ⱖ 240 mg/dL or known dyslipidemia
Child has diabetes, hypertension, BMI ⱖ 95th percentile or smokes cigarettes
Grade B
Strongly recommend
Grade B
Strongly recommend
Grade B
Strongly recommend
Grade B
Strongly recommend
Child has a moderate- or high-risk medical condition (Table 5-2)
Use Table 9-1 for interpretation of results, algorithms in Figs 9-1 and 9-2 for management.
9 to 11 y
Universal screening
Grade B
Strongly recommend
Non-FLP: Calculate non–HDL cholesterol:
Non–HDL cholesterol ⴝ TC ⴚ HDL cholesterol
If non-HDL ⱖ 145 mg/dL ⫾ HDL ⬍ 40 mg/dLb:
Obtain FLP twice,a average results
OR
FLP:
If LDL cholesterol ⱖ 130 mg/dL ⫾ non-HDL cholesterol ⱖ 145 mg/dL ⫾ HDL cholesterol ⬍ 40 mg/dL ⫾ triglycerides ⱖ 100 mg/dL
if ⬍10 y, ⱖ130 mg/dL if ⱖ10 y:
Repeat FLP, average results
Use Table 9-1 for interpretation of results, algorithms in Figs 9-1 and 9-2 for management.
12 to 16 y
No routine screeningc
Grade B
Recommend
Measure FLP twice,a average results, if new knowledge of:
Parent, grandparent with MI, angina, stroke, CABG/stent/angioplasty, sudden death at ⬍55 y in male, ⬍65 y in female
Parent with TC ⱖ 240 mg/dL or known dyslipidemia
Patient has diabetes, hypertension, BMI ⱖ 85th percentile or smokes cigarettes
Patient has a moderate- or high-risk medical condition (Table 5-2)
Grade B
Strongly recommend
Grade B
Strongly recommend
Grade B
Strongly recommend
Grade B
Strongly recommend
Use Table 9-1 for interpretation of results, algorithms in Figs 9-1 and 9-2 for management.
17 to 21 y
Universal screening once in this time period:
Grade B
Recommend
Non-FLP: Calculate non–HDL cholesterol:
Non–HDL cholesterol ⴝ TC ⴚ HDL cholesterol*
17–19 y:
If non–HDL cholesterol ⱖ145 mg/dL ⫾ HDL cholesterol ⬍ 40 mg/dLb
Measure FLP twice,a average results
OR
FLP:
If LDL cholesterol ⱖ 130 mg/dL ⫾ non–HDL cholesterol ⱖ 145 mg/dL ⫾ HDL cholesterol ⬍ 40 mg/dL ⫾ triglycerides ⱖ 130 mg/dL
Repeat FLP, average results
Use Table 9-1 for interpretation of results, algorithms in Figs 9-1 and 9-2 for management.
20–21 y:
Non–HDL cholesterol ⱖ 190 mg/dL ⫾ HDL cholesterol ⬍ 40 mg/dL
Measure FLP twice, average results
OR
FLP:
If LDL cholesterol ⱖ 160 mg/dL ⫾ non–HDL cholesterol ⱖ 190 mg/dL ⫾ HDL cholesterol ⬍ 40 mg/dL ⫾ triglycerides ⱖ 150 mg/dL
Repeat FLP, average results
Use Table 9-2 for interpretation of results, Adult Treatment Panel (ATP III) algorithm for management.
Grades reflect the findings of the evidence review, recommendation levels reflect the consensus opinion of the expert panel. Note that the values given are in mg/dL. To convert to SI units,
divide the results for TC, LDL cholesterol, HDL cholesterol, and non-HDL cholesterol by 38.6; for triglycerides, divide by 88.6. MI indicates myocardial infarction; CABG, coronary artery bypass
graft; ATP III, Adult Treatment Panel III.
a Interval between FLP measurements: after 2 weeks but within 3 months.
b Use Table 9-1 for interpretation of results; use lipid algorithms in Figs 9-1 and 9.2 for management of results.
c Disregard triglyceride and LDL cholesterol levels in nonfasting sample.
d Lipid screening is not recommended for those aged 12 to 16 years because of significantly decreased sensitivity and specificity for predicting adult LDL cholesterol levels and significantly
increased false-negative results in this age group. Selective screening is recommended for those with the clinical indications outlined.
e Use Table 9-1 for interpretation of results of 7- to 19-year-olds and lipid algorithms in Figs 9-1 and 9-2 for management. Use Table 17 for interpretation of results of 20- to 21-year-olds and
ATP III algorithms for management.
PEDIATRICS Volume 128, Supplement 5, December 2011
S239
TABLE 9-6 Risk-Factor Definitions for Dyslipidemia Algorithms
Positive family history: myocardial infarction, angina, coronary artery bypass graft/stent/angioplasty,
sudden cardiac death in parent, grandparent, aunt, or uncle at ⬍55 y for males, ⬍65 y for females
High-level RFs
Hypertension that requires drug therapy (BP ⱖ 99th percentile ⫹ 5 mm Hg)
Current cigarette smoker
BMI at the ⱖ97th percentile
Presence of high-risk conditions (Table 9-7)
(DM is also a high-level RF, but it is classified here as a high-risk condition to correspond with Adult
Treatment Panel III recommendations for adults that DM be considered a CVD equivalent.)
Moderate-level RFs
Hypertension that does not require drug therapy
BMI at the ⱖ95th percentile, ⬍97th percentile
HDL cholesterol ⬍ 40 mg/dL
Presence of moderate-risk conditions (Table 9-7)
RF indicates risk factor.
TABLE 9-7 Special Risk Conditions
High risk
T1DM and T2DM
Chronic kidney disease/end-stage renal disease/post–renal transplant
Post–orthotopic heart transplant
Kawasaki disease with current aneurysms
Moderate risk
Kawasaki disease with regressed coronary aneurysms
Chronic inflammatory disease (systemic lupus erythematosus, juvenile rheumatoid arthritis)
HIV infection
Nephrotic syndrome
atitis and require care in consultation with a lipid specialist (grade B).
In adults, use of ␻-3 fish oil has been
shown to lower the triglyceride level
by 30% to 40% and to raise the HDL
level by 6% to 17%. Experience with
fish oil in children has been limited to
small case series, and no safety concerns identified; there have been no
RCTs of fish oil in children (grade D).
Age-Based Recommendations for
Medication Therapy of Children
with Dyslipidemia
The age-specific recommendations for
pharmacologic management of
dyslipidemia are summarized in Table
9-9. Children Younger Than 10 Years
● Children younger than 10 years
should not be treated with a medication unless they have a severe primary hyperlipidemia or a high-risk
condition that is associated with serious medical morbidity (homozygous
hypercholesterolemia/LDL choles-
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EXPERT PANEL
terol level of ⱖ400 mg/dL; primary
hypertriglyceridemia with a triglyceride level of ⱖ500 mg/dL; evident CVD in the first 2 decades of
life; post– cardiac transplantation) (grade C).
Children Aged 10 to 21 Years
● Decisions regarding the need for
medication therapy should be
based on the average of results
from at least 2 FLPs obtained at
least 2 weeks but no more than 3
months apart (grade C) (Fig 9-1).
● Children with an average LDL cho-
lesterol level of ⱖ250 mg/dL or average triglyceride level of ⱖ500
mg/dL should be referred directly to
a lipid specialist (grade B).
● Children with lipid abnormalities
should have a detailed family history
taken and be assessed for causes of
hyperlipidemia, additional risk factors, and risk conditions (grade C)
(Tables 9-3, 9-6, and 9-7).
● Children with lipid abnormalities
(other than an LDL cholesterol level
of ⱖ250 mg/dL or triglyceride level
of ⬎500 mg/dL) should be managed
initially for 3 to 6 months with diet
changes (CHILD-1 ¡ CHILD-2–LDL or
CHILD-2–TG) (Table 9-8) on the basis
of specific lipid profile findings (Figs
9-1 and 9-2); if the BMI is at the
ⱖ85th percentile, add increased
physical activity, reduced screen
time, and calorie restriction. Assessment for associated secondary
causes (Table 9-3), additional risk
factors, or high-risk conditions (Tables 9-6 and 9-7) is recommended.
Children at high risk who are unlikely to achieve lipid targets with
this strategy alone (severe primary
dyslipidemia, post– cardiac transplantation) should concomitantly be
considered for initiation of medication therapy (grade C) (see “DM and
Other Conditions Predisposing to
the Development of Accelerated
Atherosclerosis”).
Treatment for children with severe elevation of LDL cholesterol is based on
assessment of lipid levels and associated risk factors or risk conditions (Tables 9-6 and 9-7; Figs 9-1 and 9-2):
● Children with an average LDL cho-
lesterol level of ⱖ250 mg/dL should
be referred directly to a lipid specialist (grade B).
● If the LDL cholesterol level remains
ⱖ190 mg/dL after a 6-month trial of
lifestyle/diet management (CHILD-1
¡ CHILD-2–LDL) for children aged
10 years and older, statin therapy
should be considered (grade A) (Fig
9-1; Table 9-11 and 9-12).
● If the LDL cholesterol level remains
ⱖ130 to ⬍190 mg/dL in a child aged
10 years or older with a negative
family history of premature CVD in
first-degree relatives and no highor moderate-level risk factor or risk
condition (Tables 9-6 and 9-7), man-
SUPPLEMENT ARTICLES
statin therapy should be considered
(grade C) (Fig 9-1; Table 9-12).
FLP x 2a, average
TG > 500 mg/dL,
Consult lipid
specialist
LDL-C > 250 mg/dL
Consult lipid
specialist
LDL-C > 130, < 250 mg/dL b**
● For children aged 8 or 9 years with
Target LDL-C
TG > 100, < 500 mg/dL, < 10 y Target TG
> 130, < 500 mg/dL, 10-19
10–19yy
(see
TGTG
algorithm,
Figure
9-2)
(see
algorithm,
Fig 9-2)
Exclude secondary causes.
Evaluate for other RFs.
Start CHILD-1 CHILD-2–LDL (Table 9-8) + lifestyle change x 6 moc
FLP
LDL-C < 130 mg/dL
Continue CHILD-2–LDL
Repeat FLP every 12 mo
LDL-C > 130 to -189 mg/dL
FHx (-)
No other RFs
Continue CHILD-2–LDL,
Follow every 6 mo with FLP,
FHx/RF update
LDL-C > 190 mg/dL
LDL-C > 160 to -189 mg/dL
FHx (+) or
1 high-level RF or
> 2 moderate-level RFs
LDL-C > 130 to -159 mg/dL +
2 high-level RFs or
1 high-level + > 2 moderatelevel RFs OR clinical CVD
Initiate statin therapy
(Tables 9-1 and 9-12)
Initiate statin therapy
(Tables 9-11 and 9-12)
Initiate statin therapy
(Tables 9-11 and 9-12)
Follow with FLPs, related chemistries per Table 9-12
LDL-C still > 130 mg/dL, TG < 200 mg/dL, refer to lipid specialist for addition of
second lipid-lowering agent; monitor per Table 9-12
In high LDL-C patients, if non–HDL-C > 145 mg/dL after effective LDL-C treatment,
Target TG (Fig 9-2)
FIGURE 9-1
Dyslipidemia algorithm: target LDL cholesterol. Values given are in mg/dL. To convert to SI units,
divide results for TC, LDL cholesterol, HDL cholesterol, and non-HDL cholesterol by 38.6; for triglycerides, divide by 88.6. TG indicates triglycerides; C, cholesterol; RF, risk factor; FHx, family history; a
Obtain FLPs at least 2 weeks but no more than 3 months apart. b Per Table 9-9, use of drug therapy is
limited to children aged 10 years and older with defined risk profiles. c In a child with an LDL
cholesterol level of ⬎190 mg/dL and other risk factors, a trial of the CHILD-2–LDL may be abbreviated.
agement should continue to be focused on diet changes (CHILD-2–
LDL) on the basis of lipid profile
findings (Fig 9-1) plus weight management if BMI is at the ⱖ85th percentile. Pharmacologic therapy is
not generally indicated, but treatment with bile acid sequestrants
might be considered, the latter in
consultation with a lipid specialist
(grade B).
● If the LDL cholesterol level remains
ⱖ160 to 189 mg/dL after a trial of
lifestyle/diet management (CHILD-1
¡ CHILD-2–LDL) in a child aged 10
years or older with a positive family
history of premature CVD/events in
first-degree relatives (Table 9-6) or
at least 1 high-level risk factor or
risk condition or at least 2
moderate-level risk factors or risk
conditions (Tables 9-6 and 9-7), then
statin therapy should be considered
(grade B) (Fig 3; Table 27).
● If the LDL cholesterol level remains
ⱖ130 to 159 mg/dL after a trial of
lifestyle/diet management (CHILD-1
¡ CHILD-2–LDL) in a child aged 10
years or older with at least 2 highlevel risk factors or risk conditions
or at least 1 high-level risk factor or
risk condition together with at least
2 moderate-level risk factors or risk
conditions (Tables 21 and 22), then
an LDL cholesterol level persistently
ⱖ190 mg/dL after a trial of lifestyle/
diet management (CHILD-1 ¡ CHILD2–LDL), together with multiple firstdegree family members with
premature CVD/events, or the presence of at least 1 high-level risk factor or risk condition or the presence
of at least 2 moderate-level risk factors or risk conditions (Fig 9-1) (Tables 9-6 and 9-7), statin therapy
might be considered (grade B) (Table 9-12)).
● Statin use should begin with the
lowest available dose given once
daily. If LDL cholesterol target levels
are not achieved with at least 3
months of compliant use, then the
dose may be increased by 1 increment (usually 10 mg). If LDL cholesterol target levels are still not
achieved with at least 3 months of
compliant use, then the dose may be
further increased by 1 increment.
The risk and effectiveness of dose
escalation have been explored in
several of the clinical trials of statins in children, and no additional
safety issues have been identified
(grade B). Alternatively, a second
agent such as a bile acid sequestrant or cholesterol absorption inhibitor may be added under the direction of a lipid specialist (grade B)
(Table 9-12).
● Children taking a statin should have
routine clinical monitoring for
symptoms of muscle toxicity and assessment of hepatic transaminases
and creatine kinase (grade A) (Table 9-12).
● Pediatric care providers should be
on the alert for, and children and
their families should be counseled
about, potential medication interactions (grade D) (Table 9-12).
PEDIATRICS Volume 128, Supplement 5, December 2011
S241
FLP x 2a, average results
TG > 500 mg/dL,
Consult lipid
specialist
LDL-C > 250 mg/dL
Consult lipid
specialist
LDL-C > 130, < 250 mg/dL **
Target LDL-C
(see (see
LDL LDL
algorithm,
Figure
algorithm,
Fig9-1)
9-1)
TG > 100, < 500 mg/dL, < 10 y
> 130, < 500 mg/dL, 10-19
10–19 yy
Target TG
CHILD-1
CHILD-2–TG
TARGET
TARGET
TGs TGs
--> Cardiovascular
Healthdiet
Integrated
(Table 9-8) +
2 TG
diet (Table
Lifestyle
Diet (CHILD
1) CHILD
lifestyle
modification
with WT-loss
goal as
needed
× 6 mo9–
needed × 6 months
with a fibrate or niacin in conjunction with referral to a lipid specialist
(grade D) (Fig 9-1) (Tables 9-10 and
9-11).
● Children with severe or complex
mixed dyslipidemias, particularly
when multiple medications are being considered, should be referred for consultation with a lipid
specialist (grade D) (Figs 9-1 and
9-2).
FLP
10. OVERWEIGHT AND OBESITY
TG < 100 mg/dL <10 y,
< 130 mg/dL, 10–19 y
TG > 100, < 200 mg/dL, <10 y
> 130, < 200 mg/dL, 10–19y
TG > 200–499 mg/dL
Continue CHILD-2–TG
+ lifestyle change
Reassess q 12 mo
Intensify CHILD-2–TG + WT loss
Increase dietary fish contentb
Repeat FLP in 6 mo
If LDL-C target achieved and non-HDL
> 145 mg/dL lipid specialist for drug
therapy (statin±fibrate±nicotinic acid)
Consider ω-3 fish-oil therapy
FIGURE 9-2
Dyslipidemia algorithm: target triglycerides. Values given are in mg/dL. To convert to SI units, divide
results for TC, LDL cholesterol, HDL cholesterol, and non-HDL cholesterol by 38.6; for triglycerides,
divide by 88.6. C indicates cholesterol; a Obtain FLPs at least 2 weeks but no more than 3 months
apart. b The FDA and the Environmental Protection Agency advise women of childbearing age who
may become pregnant, pregnant women, nursing mothers, and young children to avoid some
types of fish and shellfish and to eat fish and shellfish that are lower in mercury. For more information, call the FDA’s food information line toll-free at 1-888-SAFEFOOD or visit
www.cfsan.fda.gov/~dms/admehg3.html.
● Females taking a statin should be
counseled about risks associated
with pregnancy and appropriate
contraception strategies if indicated. Use of oral contraceptives in
combination with statins is not contraindicated (grade D) (Table 9-12).
Children with elevated triglyceride or
non-HDL cholesterol after control of
LDL cholesterol are managed on the
basis of lipid levels (Fig 9-2):
● Children with average fasting tri-
glyceride levels of ⱖ500 mg/dL or
any single measurement of ⱖ1000
mg/dL related to a primary hypertriglyceridemia should be treated in
conjunction with a lipid specialist;
the CHILD-2–TG (Table 9-8) should be
started, and use of fish oil, fibrate,
or niacin to prevent pancreatitis
should be considered (grade D) (Fig
9-2) (Tables 9-10 and 9-11).
S242
EXPERT PANEL
● Children with fasting triglyceride
levels of ⱖ200 to 499 mg/dL after a
trial of lifestyle/diet management
with CHILD-1 ¡ CHILD-2–TG (Table
9-8) should have non-HDL recalculated and be managed to a goal
level of ⬍145 mg/dL (grade
D).
● Children with fasting triglyceride
levels of ⱖ200 to 499 mg/dL, nonHDL levels of ⬎145 mg/dL, after a
trial of lifestyle/diet management
with CHILD-1 ¡ CHILD-2–TG (Table
9-8) and increased fish intake, may
be considered for fish-oil supplementation (grade D) (Table 9-10).
● Children aged 10 years or older with
non-HDL cholesterol levels of ⱖ145
mg/dL after the LDL cholesterol goal
has been achieved may be considered for further intensification of
statin therapy or additional therapy
The dramatic increases in childhood
overweight and obesity in the United
States since 1980 are an important
public health focus. Despite efforts
over the last decade to prevent and
control obesity, recent reports from
the National Health and Nutrition Examination Survey14 show sustained
high prevalence; 17% of children and
adolescents have a BMI at the ⬎95th
percentile for age and gender. The
presence of obesity in childhood and
adolescence is associated with increased evidence of atherosclerosis
at autopsy and of subclinical measures of atherosclerosis on vascular
imaging. Because of its strong association with many of the other established risk factors for cardiovascular disease, obesity is even more
powerfully correlated with atherosclerosis; this association has been
shown for BP, dyslipidemia, and insulin resistance in each of the major
pediatric epidemiologic studies. Of
all the risk factors, obesity tracks
most strongly from childhood into
adult life. Improvement in weight status and decrease in body fatness
have been shown to be associated
with improvement in all the obesityrelated risk factors and in subclinical vascular changes. Higher BMI
during childhood is directly associated with increased coronary heart
disease in adult life. Extrapolation
from current data suggests that ad-
SUPPLEMENT ARTICLES
TABLE 9-8 Evidence-Based Recommendations for Dietary Management of Elevated LDL
Cholesterol, Non-HDL Cholesterol, and Triglyceride Levels
2 to 21 y
Elevated LDL cholesterol: CHILD-2–LDL
Refer to a registered dietitian for family medical nutrition therapy
25%–30% of calories from fat, ⱕ7% from saturated fat, ⬃10%
from monounsaturated fat; ⬍200 mg/d of cholesterol;
avoid trans fats as much as possible
Supportive actions:
Plant sterol esters and/or plant stanol estersa up to 2 g/d as
replacement for usual fat sources can be used after 2 y of
age in children with familial hypercholesterolemia
Plant stanol esters as part of a regular diet are marketed
directly to the public; short-term studies have found no
harmful effects in healthy children
The water-soluble fiber psyllium can be added to a low-fat, lowsaturated-fat diet as cereal enriched with psyllium at a
dose of 6 g/d for children 2–12 y of age and 12 g/d for
those ⱖ12 y of age
As for all children, 1 h/d of moderate-to-vigorous physical
activity and ⬍2 h/d of sedentary screen time are
recommended.
Elevated triglycerides or non-HDL cholesterol: CHILD-2–TG
Refer to a registered dietitian for family medical nutrition
therapyb
25%–30% of calories from fat, ⱕ7% from saturated fat, ⬃10%
from monounsaturated fat; ⬍200 mg/d of cholesterol;
avoid trans fats as much as possible
Decrease sugar intake
Replace simple with complex carbohydrates
No sugar-sweetened beverages
Increase dietary fish to increase ␻-3 fatty acidsc
Grade B
Strongly
recommend
Grade A
Recommend
Grade B
Strongly
recommend
Grade A
Recommend
Grade B
Recommend
Grade D
Recommend
Grades reflect the findings of the evidence review; recommendation levels reflect the consensus opinion of the expert
panel; and supportive actions represent expert consensus suggestions from the expert panel provided to support
implementation of the recommendations (they are not graded). Values given are in mg/dL. To convert to SI units, divide the
results for TC, LDL cholesterol, HDL cholesterol, and non-HDL cholesterol by 38.6; for triglycerides, divide by 88.6.
a Can be found added to some foods, such as some margarines.
b If the child is obese, nutrition therapy should include calorie restriction, and increased activity (beyond that recommended
for all children) should be prescribed. See “Overweight and Obesity” for additional age-specific recommendations.
c The FDA and the Environmental Protection Agency advise women of childbearing age who may become pregnant, pregnant
women, nursing mothers, and young children to avoid some types of fish and shellfish and eat fish and shellfish that are low
in mercury. For more information, call the FDA’s food information line toll-free at 1-888-SAFEFOOD or visit
www.cfsan.fda.gov/~dms/admehg3.html.
olescent obesity will likely increase
adult coronary heart disease by 5%
to 16% over the next 25 years with
⬎100 000 excess cases of coronary
heart disease attributable to increased obesity in childhood. The
evidence review included RCTs, systematic reviews, meta-analyses, and
observational studies that assessed
the prevention and treatment of
overweight and obesity in childhood
and adolescence.
Identification of Overweight and
Obese Children and Adolescents
To identify overweight and obesity in
children living in the United States, BMI
percentile distributions relative to
gender and age on the Centers for Disease Control and Prevention (CDC)
2000 growth charts15 are now the preferred reference. The CDC growth
charts were not developed as a healthrelated standard. Instead, the growth
charts present percentiles of the BMI
distribution derived from measurements taken during several National
Health and Nutrition Examination Surveys as points of reference. Although
the charts were published in 2000, they
include selected data from the 1963
through 1980 surveys and, thus, are
not representative of the US population in 2000. These BMI percentile
growth charts provide the best reference data available for describing normal growth in US children. They are,
however, a screening tool and not an
instrument for the diagnosis of overweight and obesity.
An expert committee jointly convened
by the American Medical Association
(AMA), the CDC, and the Maternal and
Child Health Bureau (MCHB) of the
Health Resources and Services Administration (US Department of Health and
Human Services)16 recently recommended that BMI be used to assess
weight-for-height relationships in children. This conclusion was reached because BMI can be easily calculated
from height and weight, correlates
strongly with direct measures of body
fat (especially at higher BMI values),
associates only weakly with height,
and identifies those with the highest
body fat correctly with acceptable accuracy, particularly above the 85th BMI
percentile. Pediatric care providers
need a feasible standard for identifying overweight and obesity in their
patients, because parents recognize
a child’s overweight status in fewer
than half of the cases. The AMA/CDC/
MCHB expert committee16 defined a
BMI at the ⱖ95th percentile as obese
and a BMI between the 85th and 94th
percentiles as overweight; children
in the latter BMI category have a
great deal of variation with respect
to prediction of future risk. The expert panel for these guidelines concluded that BMI is a sufficient measure for screening children and
PEDIATRICS Volume 128, Supplement 5, December 2011
S243
TABLE 9-9 Evidence-Based Recommendations for Pharmacologic Treatment of Dyslipidemia
Birth to 10
y
ⱖ10 to 21 y
Pharmacologic treatment is limited to children with severe primary hyperlipidemia (homozygous familial
hypercholesterolemia, primary hypertriglyceridemia [triglycerides ⱖ 500 mg/dL]), a high-risk condition
(Tables 9-6 and 9-7), or evident cardiovascular disease, all under the care of a lipid specialist
Detailed family history and RF assessment required before initiation of drug therapya (high- to moderate-level RFs
and RCs are listed in Tables 9-6 and 9-7)
LDL cholesterol
If average LDL cholesterol ⱖ 250 mg/dLa, consult lipid specialist
If average LDL cholesterol ⱖ 130–250 mg/dL, or non-HDL ⱖ 145 mg/dL:
Refer to dietitian for medical nutrition therapy with CHILD-1 ¡ CHILD-2–LDL (Table 9-8) for 6 mo; repeat
FLP
Repeat FLP
LDL cholesterol ⬍ 130 mg/dL, continue CHILD-2–LDL, reevaluate in 12 mo
LDL cholesterol ⱖ 190 mg/dL,b consider initiation of statin therapy per Tables 9-11 and 9-12
LDL cholesterol ⱖ 130–189 mg/dL, negative family history, no other RF or RC, continue CHILD-2–LDL,
reevaluate every 6 mo
LDL cholesterol ⫽ 160–189 mg/dL ⫹ positive family history or ⱖ1 high-level RF/RC or ⱖ2 moderate-level
RFs/RCs, consider statin therapy per Tables 9-11 and 9-12
LDL cholesterol ⱖ 130–159 mg/dL ⫹ ⱖ2 high-level RFs/RCs or 1 high-level ⫹ 2 moderate-level RFs/RCs,
consider statin therapy per Tables 9-11 and 9-12
Children on statin therapy should be counseled and carefully monitored per Table 9-12
ⱖ10 to 21 y
Detailed family history and RF/RC assessment required before initiation of drug therapya (high- and moderatelevel RFs/RCs in Tables 9-6 and 9-7c)
Triglycerides
If average triglycerides ⱖ 500 mg/dL, consult lipid specialist
If average triglycerides ⱖ 100 mg/dL in a child aged ⬍10 y, ⱖ130 mg/dL in a child aged 10–19 y, or ⬍500
mg/dL:
Refer to dietitian for medical nutrition therapy with CHILD-1 ¡ CHILD-2–TG (Table 9-8) for 6 mo
Repeat FLP
Triglycerides ⬍ 100 (130) mg/dL, continue CHILD-2–TG, monitor every 6–12 mo
Triglycerides ⬎ 100 (130) mg/dL, reconsult dietitian for intensified CHILD-2–TG diet counseling
Triglycerides ⱖ 200–499 mg/dL, non-HDL ⱖ 145 mg/dL, consider fish oil ⫾ consult lipid specialist
Non-HDL cholesterol
Children aged ⱖ10 y with non-HDL cholesterol ⱖ 145 mg/dL after LDL cholesterol goal is achieved may be
considered for additional treatment with statins, fibrates, or niacin in conjunction with a lipid specialist
consultation
Grade C
Recommend
Grade C
Strongly recommend
Grade B
Strongly recommend
Grade A
Strongly recommend
Grade A
Strongly recommend
Grade A
Strongly recommend
Grade B
Recommend
Grade B
Recommend
Grade B
Recommend
Grade A
Strongly recommend
Grade C
Strongly recommend
Grade B
Recommend
Grade B
Strongly recommend
Grade B
Strongly recommend
Grade C
Recommend
Grade D
Recommend
Grade D
Optional
Grades reflect the findings of the evidence review, and recommendation levels reflect the consensus opinion of the expert panel. When medication is recommended, it should always be
in the context of the complete cardiovascular risk profile of the patient and in consultation with the patient and the family. Values given are in mg/dL. To convert to SI units, divide the results
for TC, LDL cholesterol, HDL cholesterol, and non-HDL cholesterol by 38.6; for triglycerides, divide by 88.6. RF indicates risk factor; RC, risk condition.
a Consideration of drug therapy is based on the average of ⱖ2 FLPs, obtained at least 2 weeks but no more than 3 months apart.
b If average LDL cholesterol ⱖ 190 mg/dL after CHILD-2–LDL and child is 8 to 9 years old with a positive family history or ⱖ1 high-level risk factor/risk condition or ⱖ2 moderate-level risk
factors/risk conditions, statin therapy may be considered.
c If the child is obese, nutrition therapy should include calorie restriction and increased activity beyond that recommended for all children. See “Overweight and Obesity” for additional
age-specific recommendations.
adolescents to identify those who
need evaluation for cardiovascular
risk factors associated with body adiposity. The expert panel also concluded that the scientific evidence
linking elevated BMI to cardiovascular risk factors and morbidity is
strong and well supported.
S244
EXPERT PANEL
The expert panel therefore recommends that children and adolescents
aged 2 to 18 years with a BMI at the
ⱖ95th percentile be described as
“obese” and identified as needing assessment for cardiovascular risk factors. For children with a BMI that falls
between the 85th and 95th percen-
tiles, the term “overweight” should
be used, and the position of the
child’s BMI on the growth chart
should be used to express concern
regarding weight-for-height disproportion. It is important to follow the
pattern of growth over time by using
these cut points to identify children
SUPPLEMENT ARTICLES
TABLE 9-10 Medications for Managing Hyperlipidemia
Type of
Medication
Mechanism of Action
Major Effects
Examples
Adverse Reactions
FDA Approval in Youths (as of
This Writing)
HMG-CoA reductase Inhibits cholesterol synthesis Mainly lowers LDL
inhibitors
in hepatic cells; decreases cholesterol; some
(statins)
cholesterol pool, resulting
decrease in
in upregulation of LDL
triglycerides and
receptors
modest increase in
HDL cholesterol
Atorvastatin, fluvastatin, Raised hepatic enzymes, All statins listed are approved as
lovastatin,
raised creatine kinase,
an adjunct to diet to lower LDL
pravastatin,
myopathy possibly
cholesterol in adolescent boys
rosuvastatin,
progressing to
and postmenarcheal girls aged
simvastatin
rhabdomyolysis
10–18 y (ⱖ8 y for pravastatin)
with heFH and LDL cholesterol
ⱖ190 mg/dL, or ⱖ160 mg/dL
with family history of
premature CVD and ⱖ2 CVD
risk factors in the pediatric
patient
Lowers LDL cholesterol; Cholestyramine,
Limited to gastrointestinal No pediatric indication listed for
small increase in
colestipol,
tract: gas, bloating,
cholestyramine or colestipol;
HDL cholesterol;
colesevelam
constipation, cramps
colesevelam indicated as
raises triglycerides
monotherapy or with statin for
LDL cholesterol reduction in
boys and postmenarcheal girls
aged 10–17 y with family history
after diet trial if LDL cholesterol
ⱖ 190 mg/dL or if LDL
cholesterol ⱖ 160 mg/dL with
family history of premature CVD
or ⱖ2 CVD risk factors in the
pediatric patient
Mainly lowers LDL
Ezetimibe
Myopathy, gastrointestinal Not approved
cholesterol; some
upset, headache
decrease in
triglycerides and
small increase in
HDL cholesterol
Mainly lowers
Fenofibrate, gemfibrozil Dyspepsia, constipation, Not approved
triglycerides and
myositis, anemia
raises HDL
cholesterol; little
effect on LDL
cholesterol
Bile acid
sequestrants
Binds intestinal bile acids,
interrupting enterohepatic
recirculation; more
cholesterol converted into
bile acids; decreases
hepatic cholesterol pool;
upregulates LDL receptors
Cholesterol
absorption
inhibitors
Inhibits intestinal absorption
of cholesterol and plant
sterols; decreases hepatic
cholesterol pool;
upregulates LDL receptors
Fibric acid
derivatives
Agonist for PPAR-␣ nuclear
receptors that upregulate
LPL and downregulate
apolipoprotein C-III, both
increasing degradation of
VLDL cholesterol and
triglycerides; hepatic
synthesis of VLDL
cholesterol may also be
decreased
Inhibits release of FFA from Lowers triglycerides
Niacin, extended release Flushing, hepatic toxicity, Use not recommended in
adipose tissue; decreases
and LDL cholesterol
can increase fasting
children ⬍2 y old
VLDL and LDL cholesterol
and raises HDL
blood glucose, uric
production and HDL
cholesterol; can
acid; can cause
cholesterol degradation
decrease
hyperacidity
lipoprotein(a)
Decreases hepatic FA and
Lowers triglycerides;
␻-3 acid ethyl esters
Occasional adverse
Only 1 fish-oil preparation is
triglycerides synthesis
raises HDL
gastrointestinal effects
FDA-approved for adults, but
while enhancing FA
cholesterol; increases
but no adverse effect
many generic fish-oil capsules
degradation/oxidation,
LDL cholesterol and
on glucose levels or
are commercially available
with subsequent reduced
LDL cholesterol
muscle or liver
VLDL cholesterol release
particle size
enzymes or bleeding
Nicotinic acid
(extended
release)
␻-3 fish oil
HMG-CoA indicates hydroxymethylglutaryl coenzyme A; heFH, heterozygous hypercholesterolemia; PPAR-␣, peroxisome proliferator-activated receptor; LPL, lipoprotein lipase; VLDL, very low
density lipoprotein; FFA, free fatty acid; FA, fatty acid.
Adapted from McCrindle BW, Urbina EM, Dennison BA, et al; American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee; American Heart Association, Council
of Cardiovascular Disease in the Young; American Heart Association, Council on Cardiovascular Nursing. Circulation. 2007;115(14):1948 –1967.
who require more frequent follow-up
and further assessment rather than
to assign a diagnosis. Some might
feel that “obese” is an unacceptable
term for children and parents, so as
with all health conditions, the practi-
tioner is encouraged to use descriptive terminology that is appropriate
for each child and family and to pro-
PEDIATRICS Volume 128, Supplement 5, December 2011
S245
TABLE 9-11 Clinical Trials of Lipid-Lowering Medication Therapy in Children and Adolescents
Study Authors, Type,
and Duration
Bile acid–binding resins
Tonstad et al, RCT, 1 y
McCrindle et al, RCT
crossover, 2 ⫻ 8
wk
Tonstad et al, RCT, 8
wk; open label,
44–52 wk
McCrindle et al, RCT
crossover, 2 ⫻ 18
wk
Stein et al , RCT, 8 wk;
open label, 18 wk
HMG-CoA reductase
inhibitors (statins)
McCrindle et al, RCT;
open label, 26 wk
Medication
Cholestyramine
Cholestyramine
Colestipol
Colestipol
Colesevelam
Atorvastatin
Fluvastatin
Lambert et al, RCT, 8
wk
Lovastatin
Stein et al, RCT, 48 wk Lovastatin
Clauss et al, RCT, 24
wk
Lovastatin
Knipscheer et al, RCT,
12 wk
Pravastatin
Wiegman et al, RCT, 2
y
Pravastatin
Rodenburg et al,
open-label, 2-y RCT;
4.5-y open-label
follow-up
Pravastatin
de Jongh et al, RCT,
48 wk
de Jongh et al, RCT,
28 wk
Simvastatin
EXPERT PANEL
Daily Dose
Effect on Lipid Profile, %
TC
Van der Graaf et al,
open label, 2 y
S246
No. of Subjects, Gender, Condition
Simvastatin
72, male and female, FH (LDL ⱖ 190 mg/dL
without family history of premature
CVD or LDL ⱖ 160 with family history
after 1-y diet; ages 6–11 y)
40, male and female, FH (1 parent with FH;
LDL cholesterol ⱖ 131 mg/dL; on diet;
ages 10–18 y)
66, male and female, FH (TC ⱖ 239 mg/dL
and triglycerides ⱕ 115 mg/dL; ages
10–16 y)
36, male and female, FH/FCHL (LDL ⱖ 160
mg/dL after 6 mo of diet counseling;
ages 8–18 y)
191, male and female, FH (LDL ⱖ 190 mg/
dL or LDL ⱖ plus 2 additional risk
factors after 6 mo of diet counseling;
ages 10–17 y
187, male and female, FH/severe
hyperlipidemia (LDL cholesterol ⱖ 190
mg/dL or LDL cholesterol ⱖ 160 mg/dL
with family history; triglycerides ⬍ 400
mg/dL; ages 10 – 17 y)
85, male and female, FH (LDL cholesterol
ⱖ 190 mg/dL or LDL cholesterol ⱖ 160
mg/dL and ⱖ1 risk factor or LDL
receptor mutation; ages 10–16 y)
69, male, FH (LDL cholesterol ⬎ 95th
percentile, family history of
atherosclerosis and hyperlipidemia; on
diet; mean age: 13 y)
132, male, FH (LDL 189–503 mg/dL ⫹
family history of high LDL; or 220–503
mg/dL ⫹ family history of CAD death;
AHA diet ⱖ4 mo; ages 10–17 y)
54, female, FH (family history of FH; LDL
160–400 mg/dL and triglycerides ⬍ 350
mg/dL; 4-wk diet placebo run-in and
20-wk treatment; ages 10–17 y,
postmenarcheal)
72, male and female, FH (family history
hypercholesterolemia or premature
atherosclerosis; LDL ⬎ 95th percentile;
diet for 8 wk; ages 8–16 y)
214, male and female, FH (LDL cholesterol
ⱖ 155 mg/dL and triglycerides ⱕ 350
mg/dL; diet for 3 mo; ages 8–18 y)
186, male and female, FH (LDL cholesterol
ⱖ 154 mg/dL and triglycerides ⬍ 154
mg/dL; diet for 3 mo; ages 8–18 y)
173, male and female, FH (LDL cholesterol
⫽ 158–397 mg/dL; ages 10–17 y)
50, male and female, FH (LDL cholesterol
⬎ 95th percentile, family history of
hyperlipidemia, or LDL receptor
mutation; ages 9–18 y)
LDL
HDL
Triglycerides
Cholesterol Cholesterol
8g
⫺12
⫺17
8g
⫺7 to ⫺11
⫺10 to ⫺15
2 to 4
6 to 9
2–12 g
⫺17
⫺20
⫺7
⫺13
10 g
⫺7
⫺10
2
12
1.87 g
⫺3
⫺6
5
6
3.75 g
⫺7
⫺13
8
5
10–20 mg
⫺30
⫺40
6
⫺13
80 mg
⫺27
⫺34
5
⫺5
10 mg
20 mg
30 mg
40 mg
10 mg
20 mg
40 mg
⫺17
⫺19
⫺21
⫺29
⫺13
⫺19
⫺21
⫺21
⫺24
⫺27
⫺36
⫺17
⫺24
⫺27
9
2
11
3
4
4
5
⫺18
9
3
⫺9
4
8
6
40 mg
⫺22
⫺27
3
⫺23
5 mg
10 mg
20 mg
⫺18
⫺17
⫺25
⫺23
⫺24
⫺33
4
6
11
2
7
3
20–40 mg
⫺19
⫺24
6
⫺17
20 mg (ages
⬍14 y) or
40 mg
(ages ⱖ
14 y)
10–40 mg
⫺23
⫺29
3
⫺2
⫺31
⫺41
3
⫺9
40 mg
⫺30
⫺40
5
⫺17
8
NA
SUPPLEMENT ARTICLES
TABLE 9-11 Continued
Study Authors, Type,
and Duration
Avis et al, RCT, 12 wk;
then, 40-wk openlabel follow-up
Other agents
Wheeler et al, RCT, 26
wk
Medication
No. of Subjects, Gender, Condition
Effect on Lipid Profile, %
TC
LDL
HDL
Triglycerides
Cholesterol Cholesterol
Rosuvastatin
177, male and female, FH (LDL cholesterol ⱖ
190 mg/dL or LDL cholesterol ⬎ 160 mg/
dL plus positive family history of early
CVD or ⱖ2 other risk factors for CVD)
5 mg
10 mg
20 mg
⫺30
⫺34
⫺39
⫺38
⫺45
⫺50
4
10
9
⫺13
⫺15
⫺16
Bezafibrate
14, male and female, FH (TC ⬎ 269 mg/dL,
normal triglycerides ⫹ family history
of FH or premature CAD; ages 4–15 y)
21, male and female, FH (mean LDL ⫽
243 ⫾ 45 mg/dL on low-fat diet; mean
triglycerides ⫽ 87 ⫾ 39 mg/dL; ages
4–14 y)
36, male and female, FH/FCHL (LDL ⬎ 160
mg/dL ⫹ family history of FH or
premature CAD; triglycerides ⬎ 177
mg/dL in 10 of the 36; ages 10–18 y)
10–20 mg
⫺22
NC
15
⫺23
500–2200
mg
⫺13
⫺17
4
13
Pravastatin,
10 mg
(with
colestipol,
5g)
Simvastatin
10–40 mg
(with
ezetimibe,
10 mg)
⫺13
⫺17
4
8
⫺38
⫺49
7
⫺17
NC
17 to 31
6 to 17
⫺30 to ⫺40
Colletti et al, open
label, 1–19 mo
Niacin
McCrindle et al, RCT
crossover, 2 ⫻ 18
wk
Pravastatin and
colestipol
van der Graaf et al,
RCT, 6 and 27 wk;
open label to 53
wk
Simvastatin and
ezetimibe
248, male and female, FH (LDL ⬎ 159 mg/
dL ⫹ genotype-confirmed FH or ⫹
parental genotype-confirmed FH or ⫹
parental LDL ⬎ 210 mg/dL or ⫹
tendinous xanthomas or LDL ⬎ 189
mg/dL ⫹ family history of
hypercholesterolemia; ages 10–17 y)
␻-3 fish oils (1 g
per capsule)a
—
Addendum
Goldberg et al, ␻-3
fatty acid review in
adults; no RCTs in
children
Daily Dose
1–4 g/d
FH indicates heterozygous familial hypercholesterolemia; NA, not available; FCHL, familial combined hyperlipidemia; HMG-CoA, hydroxymethylglutaryl coenzyme A; CAD, coronary artery
disease; NC, not calculated.
a There is only one FDA-approved fish-oil preparation, but there are many generic forms of fish-oil capsules that are commercially available. The University of Wisconsin maintains a
preventive cardiology patient education Web site (www.heartdecision.org). The fish-oil section includes information about the content of various preparations. The Web site is updated every
6 months (www.heartdecision.org/chdrisk/v_hd/patient_edu_docs/Fish_Oil_11-2007.pdf).
Adapted from McCrindle BW, Urbina EM, Dennison BA, et al; American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee; American Heart Association, Council
of Cardiovascular Disease in the Young; American Heart Association, Council on Cardiovascular Nursing. Circulation. 2007;115(14):1948 –1967.
vide a thorough explanation and discussion. Each patient and family
should be considered on an individual basis in deciding how best to convey the seriousness of this issue and
to develop management plans.
Conclusions of the Evidence Review on
Prevention of Overweight and Obesity
With Diet or Combined Diet and
Physical Activity Interventions
The expert panel concluded that there
is good evidence that the dietary behavior of children can safely be improved with interventions that result
in lower saturated fat intake, reduced
intake of sweetened beverages, and increased fruit and vegetable consump-
tion. In a small number of studies,
these changes were associated with
lower BMI. No evidence that diets of
this kind are harmful was identified.
Most studies also had specific interventions aimed at changing physical
activity behaviors, so it is difficult to
separate benefits related to diet
change alone. Although calorie balance is generally seen as a key issue
for weight control, intervention studies that addressed both diet and physical activity had mixed results, perhaps because most of them offered
relatively weak interventions at the
community level rather than targeting
individual at-risk youths.
The guideline recommendations for
diet and nutrition for children at elevated cardiovascular risk (CHILD-1)
(Table 5-1; “Nutrition and Diet”) specifically address optimizing the diet in
each of these areas as well as increasing intake of whole grains and matching energy intake to growth and
expenditure. For healthy children, implementation of the CHILD-1 dietary
recommendations with monitoring of
BMI and dietary intake over time
should be all that is needed from a nutritional standpoint to prevent obesity.
No additional recommendations are
indicated on the basis of this evidence
review.
PEDIATRICS Volume 128, Supplement 5, December 2011
S247
TABLE 9-12 Recommendations for Use of 3-Hydroxy-3-Methylglutaryl-Coenzyme A Reductase Inhibitors (Statins) in Children and Adolescents
Patient selection
1. Use algorithm (Fig 9-1) and risk-factor categories (Tables 9-6 and 9-7) to select statin therapy for patients.
2. Include preferences of patient and family in decision-making.
3. In general, do not start treatment with statins before the age of 10 y (patients with high-risk family history, high-risk conditions, or multiple risk factors
[Tables 9-6 and 9-7] might be considered for medication initiation at age ⱕ10 y).
4. Precaution/contraindication with potentially interactive medications (cyclosporine, niacin, fibric acid derivatives, erythromycin, azole antifungal agents,
nefazodone, many HIV protease inhibitors); check for potential interaction with all current medications at baseline.
5. Conduct baseline hepatic panel and CK before initiating treatment.
Initiation and titration
1. Choice of particular statin is a matter of preference. Clinicians are encouraged to develop familiarity and experience with one of the statins, including
dosage regimen and potential drug-drug interactions.
2. Start with the lowest dose once daily, usually at bedtime. Atorvastatin and rosuvastatin can be taken in the morning or evening because of their long
half-lives.
3. Measure baseline CK, ALT, and AST.
4. Instruct the patient to report all potential adverse effects, especially muscle cramps, weakness, asthenia, and more diffuse symptoms suggestive of
myopathy.
5. Advise female patients about concerns with pregnancy and the need for appropriate contraception.
6. Advise about potential future medication interactions, especially cyclosporine, niacin, fibric acid derivatives, erythromycin, azole antifungal agents,
nefazodone, and HIV protease inhibitors.
Check for potential interaction whenever any new medication is initiated.
1. Whenever potential myopathy symptoms are present, stop medication and assess CK; determine relation to recent physical activity. The threshold for
worrisome level of CK is 10 times above the upper limit of reported normal, considering the impact of physical activity. Monitor the patient for resolution
of myopathy symptoms and any associated increase in CK level. Consideration can be given to restarting the medication once symptoms and laboratory
abnormalities have resolved.
2. After 4 wk, measure FLP, ALT, and AST and compare with laboratory-specific reported normal values.
The threshold for worrisome levels of ALT or AST is ⱖ3 times the upper limit of reported normal.
Target levels for LDL cholesterol: minimal, ⬍130 mg/dL; ideal, ⬍110 mg/dL.
3. If target LDL cholesterol levels are achieved and there are no potential myopathy symptoms or laboratory abnormalities, continue therapy and recheck FLP,
ALT, and AST in 8 wk and then in 3 mo.
4. If laboratory abnormalities are noted or symptoms are reported, temporarily withhold the medication and repeat the blood work in 2 wk. When
abnormalities resolve, the medication may be restarted with close monitoring.
5. If target LDL cholesterol levels are not achieved, increase the dose by 1 increment (usually 10 mg) and repeat the blood work in 4 wk. If target LDL
cholesterol levels are still not achieved, dose may be further increased by 1 increment, or another agent (bile acid sequestrant or cholesterol absorption
inhibitor) may be added under the direction of a lipid specialist.
Maintenance monitoring
1. Monitor growth (height, weight, and BMI relative to normal growth charts), sexual maturation, and development.
2. Whenever potential myopathy symptoms present, stop medication and assess CK.
3. Monitor FLP, ALT, and AST every 3–4 mo in the first year, every 6 mo in the second year and beyond, and whenever clinically indicated.
4. Monitor and encourage compliance with lipid-lowering dietary and medication therapy. Serially assess and counsel for other risk factors such as weight
gain, smoking, and inactivity.
5. Counsel adolescent girls about statin contraindications in pregnancy and the need for abstinence or use of appropriate contraceptive measures. Use of oral
contraceptives is not contraindicated if medically appropriate. Seek referral to an adolescent medicine or gynecologic specialist as appropriate.
CK indicates creatine kinase; ALT, alanine aminotransferase; AST, aspartate aminotransferase.
Conclusions of the Evidence
Review on Prevention of
Overweight and Obesity With
Physical Activity
A moderate number of RCTs have evaluated the effect of interventions that
addressed only physical activity
and/or sedentary behavior on prevention of overweight and obesity. In a
small number of these studies, the intervention was effective. It should be
noted that these successful interventions often addressed reduction in
sedentary behavior rather than at-
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EXPERT PANEL
tempts to increase physical activity. In
a majority of the studies there was no
significant difference in body-size measures. Sample sizes were often small,
and follow-up was often short (frequently ⬍6 months). It is suggested
that gender-specific programs might
be more successful in changing activity
behavior. Overall, the expert panel concluded that on the basis of the evidence
review, increasing activity in isolation
is of little benefit in preventing obesity.
By contrast, the review suggests that
reducing sedentary behavior might be
beneficial in preventing the development of obesity. The activity recommendations in the guideline specifically address limiting sedentary
behavior and increasing physical activity in all children. Guidance on
amounts and intensity of physical activity and limitations on sedentary
screen time are provided in the recommendations in “Physical Activity.” On
the basis of this evidence review, no
additional specific recommendations
addressing physical activity in preventing obesity are indicated.
SUPPLEMENT ARTICLES
Summary of the Evidence Review
of Children at Increased Risk for
Overweight and Obesity
Certain populations of children who
are of normal weight are at risk for
developing overweight and obesity as
they grow older. Observational studies
have identified risk factors that put
these children at greater risk; however, research is lacking regarding an
appropriate intervention. Despite that
fact, epidemiologic associations suggest that primary care providers
should be alert to increasing BMI
trends and excessive weight gain beyond what is anticipated for height increase when dealing with these children and consider intervention before
the child becomes overweight.
Observational studies have identified
sample populations that are at special
risk for obesity:
● children with a BMI between the
85th and 95th percentiles;
● children in whom there is a positive
family history of obesity in 1 or both
parents;
● early onset of increasing weight be-
yond that appropriate for increase in
height, which can be identified early
(beginning in the first year of life);
● excessive increase in weight during
adolescence, particularly in black
girls; and
● children who have been very active
and then become inactive or adolescents who are inactive in general
(an example would be a child who
previously participated in organized
sports and has stopped, particularly in adolescence).
No RCTs that addressed these populations were identified. Despite this fact,
the expert panel believes that lifestyle
recommendations with a goal of prevention of excessive weight gain are
needed for normal-weight children
with characteristics consistent with
special risk for development of over-
weight and obesity. The diet and activity recommendations proposed for
children at elevated cardiovascular
risk (“Nutrition and Diet”; “Physical Activity”) should be vigorously reinforced
in these children. In any child, the development of a BMI between the 85th
and 95th percentile should be taken as
a sign that increased attention to diet
and activity as well as BMI-specific
follow-up is indicated.
Conclusions and Grading of the
Evidence Review on Treatment of
Obesity
● There is good evidence for the effec-
tiveness of combined weight-loss
programs that included behaviorchange counseling, negative energy
balance through diet, and increased
physical activity in addressing obesity in children older than 6 years
with a BMI at the ⱖ95th percentile
and no comorbidities (grade A).
However, such programs have been
effective primarily in a comprehensive weight-loss program or in research settings; only a small number
have been shown to be effective in primary care settings.
● No data were identified on weight-
loss programs for children younger
than 6 years.
● No single negative-energy diet plan
was identified from the evidence review. Dietary plans should be determined for each child on the basis of
baseline body size, energy requirements for growth, and physical activity
level (grade D).
fects on obesity in children and
adolescents.
● For children aged 6 to 12 years:
●
Family-based programs in research settings that addressed
both diet and activity have been
shown to be effective at initiating
and sustaining weight loss over a
follow-up of 10 years (grade A).
●
The greatest weight loss is achieved
when parents are the focus of the intervention (grade A).
● For adolescents:
●
Comprehensive programs in research settings were effective at
achieving weight loss in the
short-term (grade A).
●
The greatest weight change was
achieved when the adolescent
was the primary focus of the intervention (grade B).
●
Behavior-change programs that
involved peers resulted in more
sustained weight loss (grade B).
● In overweight and obese youth, the
combination of diet and a specific
physical activity intervention that
reduced sedentary activity and/or
increased physical activity was universally more effective at achieving
decreases in weight and BMI as well
as decreases in body fat compared
with an isolated diet intervention:
●
In both children and adolescents,
exercise training improved weight
loss and body composition (decreasing fat mass and reducing
visceral fat), decreased insulin resistance, reduced BP, normalized
dyslipidemia, and normalized subclinical measures of atherosclerosis (grade A).
●
In children aged 7 to 12 years, reduction in sedentary activity independent of increasing physical
activity produced weight loss
(grade B). In this age group, reductions in sedentary activity
● Increasing dietary fiber from corn
bran, wheat flour, wheat bran, oat
flakes, corn germ meal, or glucomannan does not significantly improve weight loss (grade A).
● Various diets, including low-glycemic-
load diets, low-carbohydrate diets, fiber supplements, and proteinsparing modified fasts, have not
been adequately studied as to their ef-
PEDIATRICS Volume 128, Supplement 5, December 2011
S249
TABLE 10-1 Evidence-Based Recommendations for Management of Overweight and Obesity
Birth to 24 mo
2 to 5 y
No weight-for-height–specific recommendations
CHILD-1 diet is recommended for pediatric care providers to use with their child and adolescent patients to reduce
cardiovascular risk
Identify children at high risk for obesity because of parental obesity and excessive BMI increase
Focused CHILD-1 diet and physical activity education
BMI percentile stable: reinforce current program, follow-up in 6 mo
Increasing BMI percentile: RD counseling for energy-balanced diet, intensify physical activity change; 6-mo follow-up
BMI ⫽ 85th–95th percentile
Excess weight-gain prevention with parents as focus for energy-balanced diet; reinforce physical activity
recommendations for 6 mo
Improvement in BMI percentile: continue current program
Increasing BMI percentile: RD counseling for energy-balanced diet; intensify physical activity recommendations;
6-mo follow-up
BMI ⱖ 95th percentile
Specific assessment for comorbiditiesa
Family-based weight-gain prevention with parents as focus; RD counseling and follow-up for energy-balanced diet;
MVPA prescription; limit sedentary screen time; 3-mo follow-up
Identify children at increased risk for obesity because of parental obesity, change in physical activity ⫾ excessive gain in
BMI for focused CHILD-1 diet/physical activity education
BMI percentile stable: reinforce current program, 6-mo follow-up
Increasing BMI percentile: RD counseling for energy-balanced CHILD-1 diet, intensified physical activity, 3 mo follow-up
BMI ⫽ 85th–95th percentile
Excessive weight-gain prevention with parents as focus for energy-balanced diet; reinforce physical activity
recommendations, 6-mo follow-up
Stable/improving BMI percentile: reinforce current program, 6-mo follow-up
Increasing BMI percentile: RD counseling for energy-balanced CHILD-1 diet, intensified physical activity
recommendations, 3-mo follow-up
BMI ⱖ 95th percentile
Specific assessment for comorbiditiesa
6 to 11 y
BMI ⱖ 95th percentile with no comorbidities
Office-based weight-loss plan: family-centered program with parents as focus for behavior modification, (⫺)
energy-balanced diet, counseling by RD, prescription for increased MVPA, decreased sedentary time for 6 mo
Improvement in BMI percentile/comorbidities: continue current plan
No improvement in BMI percentile: refer to comprehensive multidisciplinary lifestyle weight-loss program
BMI ⱖ 95th percentile with comorbidities, BMI ⬎ 97th percentile, or progressive rise in BMI despite therapy
Refer to comprehensive multidisciplinary weight-loss program for intensive management for 6 mo
Improvement in BMI percentile: continue current program
No improvement in BMI percentile: consider referral to another comprehensive multidisciplinary weight-loss program
Identify adolescents at increased risk for obesity because of parental obesity, change in physical activity ⫾ excess gain
in BMI for focused diet/physical activity education for 6 mo
BMI/BMI percentile stable: reinforce current program, 6-mo follow-up
Increasing BMI/BMI percentile: RD counseling for energy-balanced CHILD-1 diet, intensified physical activity for 3 mo
BMI ⫽ 85th–95th percentile
Excess weight-gain prevention with adolescent as change agent for energy-balanced CHILD-1 diet, reinforced physical
activity recommendations for 6 mo
Improvement in BMI percentile: continue current program
Increasing BMI percentile: RD counseling for energy-balanced weight-control diet, intensified physical activity, 3-mo
follow-up
BMI ⱖ 95th percentile
Specific assessment for comorbiditiesa
BMI ⱖ 95th percentile with no comorbidities
Office-based weight-loss plan: family-centered with adolescent as change agent for behavior-modification
counseling, RD counseling for (⫺) energy-balanced diet, prescription for increased MVPA, decreased
sedentary time for 6 mo
Improvement in BMI/BMI percentile: continue current program
No improvement in BMI/BMI percentile: refer to comprehensive multidisciplinary weight-loss program with peers
No improvement in BMI/BMI percentile: consider initiation of medication (orlistat) under care of experienced
clinician for 6–12 mo
BMI ⱖ 95th percentile with comorbidities or BMI ⬎ 35
Refer to comprehensive lifestyle weight-loss program for intensive management for 6–12 mo
Improvement in BMI/BMI percentile: continue current program
No improvement in BMI/BMI percentile: consider initiation of orlistat under care of experienced clinician for 6–12 mo
If BMI is far above 35 and comorbidities unresponsive to lifestyle therapy for ⬎1 y, consider bariatric
surgery/referral to center with experience/expertise in procedures
12 to 21 y
Grade B
Recommend
Grade D
Recommend
Grade B
Strongly recommend
Grade B Recommend
Grade B
Recommend
Grade D
Recommend
Grade B
Strongly recommend
Grade A
Strongly recommend
Grade A
Strongly recommend
Grade B
Recommend
Grade B
Recommend
Grade B
Strongly recommend
Grade B
Strongly recommend
Grade A
Strongly recommend
Grades reflect the findings of the evidence review, and recommendation levels reflect the consensus opinion of the expert panel. RD indicates registered dietitian; MVPA, moderate-tovigorous physical activity.
a Comorbidities: hypertension, dyslipidemia, and T2DM.
were effectively accomplished by
rewarding children for time
spent being physically active with
TV-viewing time (grade B).
● Girls did not respond as well as
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EXPERT PANEL
boys to combined treatments
that both reduced sedentary behaviors and increased physical
activity (grade B).
● For adolescents with or without sig-
nificant comorbidities and a BMI at
the ⬎95th percentile and for adolescents with a BMI of ⬎35 who
have failed to lose weight in a comprehensive lifestyle weight-loss pro-
SUPPLEMENT ARTICLES
gram, addition of medication under
the care of a physician experienced
in managing weight loss with medication can be safe and effective in
achieving weight loss with follow-up
of 4 to 12 months. However, longterm safety and efficacy data are
not available:
●
●
In adolescents with severe obesity and insulin resistance, the
addition of metformin to a comprehensive lifestyle weight-loss
program improved fasting insulin levels and significantly reduced weight and BMI (grade B).
(Metformin is currently approved
by the US Food and Drug Administration [FDA] for pediatric patients aged 10 years or older with
T2DM but is not approved for
weight loss for either children or
adults.)
For obese adolescents older than
12 years, the addition of orlistat
to a comprehensive lifestyle
weight-loss program improved
weight loss and BMI (grade A);
however, use of this medication
had a high rate of adverse gastrointestinal effects. (Orlistat [under
the trade name Xenical (Roche
Pharmaceuticals, Nutley, NJ)] is
approved by the FDA for weight
loss in pediatric patients 12 years
of age and older in conjunction
with a reduced-calorie diet. In August 2009, the FDA released an
early communication about an
ongoing safety review regarding
reports of liver-related adverse
events in some patients taking
orlistat. In May 2010, the orlistat
labeling was updated to incorporate safety information pertaining to the occurrence of rare
postmarketing cases of severe
liver injury, including hepatic failure that resulted in liver transplant or death.)
● Dropout rates are substantial for all
weight-treatment programs.
● No studies defining an appropriate
rate for weight loss in any age group
were identified by the guidelines evidence review. The 2010 DGA8 recommends slowing weight gain while
allowing normal growth and development. For those with a BMI at the
⬎95th percentile without comorbidities, both the AMA/CDC/MCHB expert committee and the AAP16 recommend weight maintenance resulting
in decreasing BMI as age increases.
With a BMI at the ⬎95th percentile
with comorbidities, the AMA/CDC/
MCHB expert committee and the AAP16
recommend gradual weight loss not
to exceed 1 lb/month in children aged
2 to 11 years or 2 lb/week in adolescents (no grade).
● For adolescents with a BMI far
above 35 and associated comorbidities, bariatric surgery on a research
protocol in conjunction with a comprehensive lifestyle weight-loss program improved weight loss, BMI,
and other outcomes such as insulin
resistance, glucose tolerance, and
cardiovascular measures in small
case series (grade D).
The recommendations for management of overweight and obesity are
listed in Table 10-1.
11. DM AND OTHER CONDITIONS
PREDISPOSING TO THE
DEVELOPMENT OF ACCELERATED
ATHEROSCLEROSIS
DM is an established risk factor for
early CVD. Metabolically, DM is characterized by hyperglycemia caused by
defects in insulin secretion (T1DM)
and insulin function and/or secretion
(T2DM). Both T1DM and T2DM are associated with vascular disease. Results
of autopsy and noninvasive imaging
studies suggest that the extent of vascular involvement reflects the duration of the disease and the severity of
the chronic metabolic derangement.
The epidemiologies of the 2 types differ
significantly. T1DM presents at a
younger age; 25% of patients are diagnosed between the ages of 5 and 10
years and another 40% between the
ages of 10 and 15 years. If not treated
adequately, the degree of hyperglycemia is severe, and patients are highly
symptomatic. By contrast, with T2DM,
the majority of patients present in
adult life, but a small and growing
number present in adolescence, and
most are relatively asymptomatic with
only mild-to-moderate hyperglycemia
in combination with obesity. Regardless of these differences, children with
DM, type 1 or 2, are at significantly increased risk for accelerated atherosclerosis and early CVD.
In certain other pediatric disease
states, the process of atherosclerosis
is dramatically accelerated with clinical coronary events occurring in childhood and very early adult life. These
conditions were the subject of a recent
guideline from the American Heart Association (AHA).17 The expert panel
elected to use the AHA guideline as a
template for developing recommendations for children with conditions such
as DM that predispose them to very accelerated atherosclerosis, because
the evidence review identified only a
small number of studies that addressed these conditions in an RCT.
Conclusions of the Evidence
Review for DM and Other
Predisposing Conditions
Children with DM, T1DM or T2DM, represent the prototype of the child at special
risk for accelerated atherosclerosis and
early clinical CVD. To maximize identification of T2DM in childhood and adolescence, the screening algorithm from the
American Diabetes Association18 is recommended for screening in all children
(Table 11-1).
Limited high-quality studies that ad-
PEDIATRICS Volume 128, Supplement 5, December 2011
S251
TABLE 11-1 American Diabetes Association (ADA) Screening Recommendations for Type 2
DM in Childhood
Criteria:
● Overweight, defined by:
–BMI ⱖ 85th percentile for age and gender, or
–Weight for height ⱖ 85th percentile, or
–Weight ⬎ 120% of ideal for height
Plus any two of the following risk factors:
● Family history of type 2 DM in first- or second-degree relative
● Race/ethnicity (Native American, African-American, Latino, Asian-American, Pacific Islander)
● Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans,
hypertension, dyslipidemia, or polycystic ovary syndrome)
Screening procedure:
Age of initiation:
ⱖ10 y, or at onset of puberty, if puberty occurs at a younger age
Frequency:
Every 2 y
Test:
Fasting plasma glucose
Reproduced with permission from American Diabetes Association. Diabetes Care. 2000;23(3):386.
TABLE 11-2 Special Risk Pediatric Conditions: Stratification by Risk Category
High risk
Manifest coronary artery disease at ⱕ30 y of age: clinical evidence
T1DM or T2DM
Chronic kidney disease/end-stage renal disease/post–renal transplant
Post–orthotopic heart transplantation
Kawasaki disease with current coronary aneurysms
Moderate risk
Accelerated atherosclerosis: pathophysiologic evidence
Kawasaki disease with regressed coronary aneurysms
Chronic inflammatory disease (systemic lupus erythematosus, juvenile rheumatoid arthritis)
HIV infection
Nephrotic syndrome
Adapted from Kavey RE, Allada V, Daniels SR, et al; American Heart Association, Expert Panel on Population and Prevention
Science; American Heart Association, Council on Cardiovascular Disease in the Young; American Heart Association, Council
on Epidemiology and Prevention; American Heart Association, Council on Nutrition, Physical Activity and Metabolism;
American Heart Association, Council on High Blood Pressure Research; American Heart Association, Council on Cardiovascular Nursing; American Heart Association, Council on the Kidney in Heart Disease; Interdisciplinary Working Group on
Quality of Care and Outcomes Research. Circulation. 2006;114(24):2710 –2738.
dressed cardiovascular risk reduction
in children with conditions predisposing them to accelerated atherosclerosis were found, so the expert panel
elected to modify the recommendations of an expert pediatric panel convened by the AHA that published its
recommendations for risk-factor management in 2006; these recommendations have been endorsed by the AAP
and are included in the guideline database for these guidelines.17
The authors of the AHA statement recommended specific risk identification
and management stratified according
to risk on the basis of defined other
conditions that parallel the recommendations for adults with DM or
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EXPERT PANEL
other CVD equivalents. For those in the
high-risk category (Table 11-2), the disease process has been associated
with clinical coronary disease before
30 years of age. For those in the
moderate-risk category, the disease
process has been shown to be associated with pathologic, physiologic, or
subclinical evidence of accelerated
atherosclerosis.
The expert panel believes that these
recommendations should be used for
the management of children and adolescents with DM and other predisposing conditions as outlined in the algorithm in Fig 11-1 and in Tables 11-2 and
11-3. With the growing evidence of vascular disease in children with T2DM,
the expert panel felt that it was prudent to include both T1DM and T2DM in
the high-risk category. With increasing
evidence of vascular dysfunction in
children with HIV infection and nephrotic syndrome, these 2 conditions
have been added to the selected disease settings in the moderate-risk category. Patients in the high-risk category require intensive management
with more aggressive goals for therapy than those in the moderate-risk
category, as outlined in the algorithm.
12. RISK-FACTOR CLUSTERING AND
THE METABOLIC SYNDROME
Traditional cardiovascular risk factors
such as obesity, hypertension, and dyslipidemia demonstrate clustering in
youth. Risk behaviors such as smoking, suboptimal diet, and sedentary behavior also demonstrate clustering, as
do advantageous diet and exercise
habits. Becoming obese increases the
prevalence of the risk-factor cluster in
adults called the metabolic syndrome.
The metabolic syndrome is defined as
ⱖ3 of the following risk factors: elevated
waist circumference, triglyceride levels,
BP, and/or fasting glucose level and reduced HDL cholesterol level. In the United
States, the metabolic syndrome is said to
affect between 34% and 39% of adults,
including 7% of men and 6% of women in
the 20- to 30-year-old age group. The expert panel reviewed all the RCTs, systematic reviews, meta-analyses, and observational studies that addressed the
childhood association between the riskfactor cluster known as the metabolic
syndrome and the development of atherosclerosis, and the identification and
management of the cluster in children
and adolescents.
There is a lack of consensus on how to
define metabolic syndrome in youth,
which has led to widely varying estimates of its frequency. A recent analysis
of National Health and Nutrition Examination Survey data from 1999 to 200219
SUPPLEMENT ARTICLES
Tier I: High Risk
Step 1.
RISK
STRATIFICATION
BY DISEASE
PROCESS
Tier II: Moderate Risk
T1DM and T2DM
Chronic kidney disease/end stage
renal disease/ post–kidney transplant
Post–heart transplant
Kawasaki disease with current
coronary artery aneurysms
Kawasaki disease with regressed
coronary aneurysms
Chronic inflammatory disease
HIV
Nephrotic syndrome
CV RISK FACTORS/ COMORBIDITIES
Step 2.
ASSESS
CV RFs
(> 2 RFs Move to tier 1)
Family history of early CVD in expanded first-degree pedigree (♂ ≤55 y;
♀ ≤65 y)
FLP
Smoking history
BP (3 separate occasions), interpreted for age/gender/HT percentile (%ile)
HT, WT, BMI
FG
Diet, physical activity/exercise history
No
Yes
Step 3.
TIERSPECIFIC CUT
POINTS/
TREATMENT
GOALS
Step 4:
LIFESTYLE
CHANGE
Tier 1: High Risk
BMI < 85th%ile for age/gender.
BP < 90th %ile for age/gender/HT%ile
Lipids (mg/dL): LDL-C < 100,
TG < 90, non–HDL-C < 120
FG < 100 mg/dL, HgbA1c < 7%
Intensive lifestyle management
CHILD-1a, Activity Rxb
WT loss as neededc
Tier II: Moderate Risk
BMI ≤ 90%ile for age/gender
BP ≤ 95%ile for age/gender/HT%ile
Lipids (mg/dL): LDL-C ≤ 130,
TG < 130, non–HDL-C < 140
FG < 100 mg/dL, HgbA1c < 7%
Intensive lifestyle management
CHILD-1a, Activity Rxb
Weight loss as neededc
PLUS
Step 5:
DRUG
THERAPY
Condition-specific
management – Table 11-3
If goals not met, consider
medication per risk-specific
guideline recommendations
Directions: Step 1: Risk stratification by disease process (Table 11-2).
Step 2: Assess all cardiovascular risk factors. If there are >2 comorbidities,
move tier II patient to tier I for subsequent management.
Step 3: Tier-specific treatment goals/cut points defined.
Step 4: Initial therapy: For tier I, initial management is therapeutic lifestyle
change PLUS disease-specific management (Table 11-3). For tier II, initial
management is therapeutic lifestyle change.
FIGURE 11-1
Risk stratification and management for children with conditions predisposing to accelerated atherosclerosis and early CVD. CV indicates
cardiovascular; RF, risk factor; HT, height; WT, weight; TG, triglycerides; %ile, percentile; C, cholesterol; FG, fasting glucose; Rx, recommendation. a See
“Nutrition and Diet”; b see “Physical Activity”; c see “Overweight and Obesity.” Adapted from Kavey RE, Allada V, Daniels SR, et al; American Heart Association,
Expert Panel on Population and Prevention Science; American Heart Association, Council on Cardiovascular Disease in the Young; American Heart
Association, Council on Epidemiology and Prevention; American Heart Association, Council on Nutrition, Physical Activity and Metabolism; American Heart
Association, Council on High Blood Pressure Research; American Heart Association, Council on Cardiovascular Nursing; American Heart Association, Council
on the Kidney in Heart Disease; Interdisciplinary Working Group on Quality of Care and Outcomes Research. Circulation. 2006;114(24):2710 –2738.
yielded prevalence estimates for all
teens from 2.0% to 9.4% and for obese
teens from 12.4% to 44.2%. Regardless of
the definition used, the prevalence of the
metabolic syndrome risk-factor cluster
is higher in older (12- to 14-year-old)
compared with younger (8- to 11-yearold) children. The specific etiology of
metabolic syndrome is unknown; however, it is most likely caused by the expression of various genotypes modified
by environmental interactions and mediated through abdominal obesity and insulin resistance. Longitudinal studies of
cohorts in which the metabolic syndrome cluster was present in childhood
identified an increased incidence of both
T2DM and clinical cardiovascular events
over a follow-up period of 25 years.4 A
strong association between obesity with
or without elevated insulin levels and/or
hypertension in early childhood and subsequent development of the metabolic
syndrome constellation in adulthood has
PEDIATRICS Volume 128, Supplement 5, December 2011
S253
TABLE 11-3 Condition-Specific Treatment Recommendations for High-Risk Conditions
● The presence of any combination of
Rigorous age-appropriate education in diet, activity, smoking cessation for all
Specific therapy as needed to achieve BP, LDL cholesterol, glucose, and HbA1c goals indicated for each
tier, as outlined in algorithm; timing individualized for each patient and diagnosis
DM regardless of type:
For T1DM, intensive glucose management per endocrinologist with frequent glucose monitoring/insulin
titration to maintain optimal plasma glucose and HbA1c levels for age
For T2DM, intensive weight management and glucose control in consultation with an endocrinologist as
needed to maintain optimal plasma glucose and HbA1c levels for age
Assess BMI and fasting lipid levels: step 4 lifestyle management of weight and lipid levels for 6 mo
If LDL goals are not achieved, consider statin therapy if age is ⱖ10 y to achieve tier 1 treatment goals
for LDL cholesterol
Initial BP ⱖ 90th percentile: step 4 lifestyle management plus no added salt, increased activity for 6 mo
If BP is consistently at the ⱖ95th percentile for age/gender/height, initiate angiotensin-converting
enzyme inhibitor therapy with a BP goal of ⬍90th percentile for gender/height or ⬍120/80 mm Hg,
whichever is lower
Chronic kidney disease/end-stage renal disease/post–renal transplant:
Optimization of renal-failure management with dialysis/transplantation per nephrology
Assess BMI, BP, and lipid and FG levels: step 4 lifestyle management for 6 mo
If LDL goals are not achieved, consider statin therapy if age is ⱖ10 y to achieve tier 1 treatment goals
for LDL cholesterol
If BP is consistently at the ⱖ95th percentile for age/gender/height, initiate angiotensin-converting
enzyme inhibitor therapy with a BP goal of ⬍90th percentile for gender/height or ⬍120/80 mm Hg,
whichever is lower
After heart transplantation:
Optimization of antirejection therapy, treatment for cytomegalovirus infection, routine evaluation by
angiography/perfusion imaging per transplant physician
Assess BMI, BP, and lipid and FG levels: initiate step 5 therapy, including statins, immediately for all
patients aged ⱖ1 y to achieve tier 1 treatment goals
Kawasaki disease with current coronary aneurysms:
Antithrombotic therapy, activity restriction, ongoing myocardial perfusion evaluation per cardiologist
Assess BMI, BP, and lipid and FG levels: step 4 lifestyle management for 6 mo
If goals are not achieved, consider pharmacologic therapy for LDL cholesterol and BP if age is ⱖ10 y to
achieve tier 1 treatment goals
multiple risk factors should prompt intensification of therapy with an emphasis on lifestyle modification to address
individual metabolic syndrome riskfactor levels.
● The presence of obesity should
prompt specific evaluation for all
other cardiovascular risk factors including family history of premature
CVD, hypertension, dyslipidemia,
DM, and tobacco exposure.
● The coexistence of obesity with any
other major cardiovascular risk factor should be recognized by clinicians as a setting in which:
●
intensive weight reduction should
be undertaken per the recommendations in “Overweight and Obesity,” along with management of
identified risk factors including initiation of pharmacologic therapy,
per the risk-factor–specific sections in these guidelines (“High BP”;
“Lipids and Lipoproteins”; “DM and
Other Conditions Predisposing to
the Development of Accelerated
Atherosclerosis”; “Tobacco Exposure”); and
●
prompt evaluation for DM, liverfunction abnormalities, left ventricular hypertrophy, and sleep
apnea should be undertaken.
FG indicates fasting glucose.
Adapted from Kavey RE, Allada V, Daniels SR, et al; American Heart Association, Expert Panel on Population and Prevention
Science; American Heart Association, Council on Cardiovascular Disease in the Young; American Heart Association, Council
on Epidemiology and Prevention; American Heart Association, Council on Nutrition, Physical Activity and Metabolism;
American Heart Association, Council on High Blood Pressure Research; American Heart Association, Council on Cardiovascular Nursing; American Heart Association, Council on the Kidney in Heart Disease; Interdisciplinary Working Group on
Quality of Care and Outcomes Research. Circulation. 2006;114(24):2710 –2738.
been consistently demonstrated. Treatment of cardiovascular risk-factor clustering in youth has not been thoroughly
evaluated, but maintenance of low levels
of cardiovascular risk factors starting in
childhood is associated with a lower
prevalence of CVD and increased longevity in adult life.
RECOMMENDATIONS FOR
MANAGEMENT OF RISK-FACTOR
CLUSTERING AND THE METABOLIC
SYNDROME
The metabolic-syndrome concept is important, because it identifies a common
multiple cardiovascular-risk phenotype
in pediatrics. However, the absence of a
defined etiology, the lack of consensus
on definition, and the paucity of highS254
EXPERT PANEL
level evidence addressing management
in childhood led the expert panel to conclude that the metabolic syndrome
should not be considered as a separate
risk factor in childhood and adolescence. Prevention of obesity is the most
important strategy for lowering the
prevalence of metabolic syndrome in
adults, and this seems strongly applicable in childhood (see “Overweight and
Obesity”). Given the strong relationship
of obesity and physical inactivity to the
metabolic syndrome and insulin resistance, the expert panel makes the following recommendations. Because of the
paucity of evidence available, the recommendations are a consensus of the expert panel (grade D).
These recommendations are supported
by the knowledge that cardiovascular morbidity has a continuous relationship across the risk-distribution
spectrum and that a youth with multiple borderline risk factors might, in
fact, have risk equivalent to a person
with extreme abnormality of a single
major risk factor. A presentation such
as this should lead to intense nutrition
and exercise management with close
follow-up, and if lifestyle intervention
is unsuccessful, consideration should
be given to endocrine referral. Table
12-1 provides definitions of component
risk-factor levels for evaluating chil-
SUPPLEMENT ARTICLES
TABLE 12-1 Metabolic Syndrome Component Levels for Evaluation of Children With Multiple
Cardiovascular Risk Factors
Risk Factor
Obesity, percentile
BMI
Waist circumference
BP, percentile
Cut Point
Reference
ⱖ85th to ⬍95th
ⱖ90th to ⬍95th
ⱖ90th to ⬍95th
CDC growth charts
NHANES
“The Fourth Report on the Diagnosis,
Evaluation and Treatment of High
Blood Pressure in Children and
Adolescents”
See “Lipids and Lipoproteins” for
normative values
Dyslipidemia, mg/dL
HDL cholesterol
Triglycerides
0–9 y
ⱖ10 y
Non-HDL cholesterol
Glycemia, mg/dL
Fasting glucose
Fasting insulin
ⱖ40 to ⱕ45
ⱖ75 to ⬍100
ⱖ90 to ⬍130
ⱖ120 to ⬍144
ADA screening recommendations
ⱖ100 to ⬍126
Elevated fasting insulin level, above
normal for gender, race, and
pubertal status, is considered
evidence of insulin resistance
TABLE 13-1 Evidence-Based Recommendations for Maternal Smoking Cessation
Grade A, strongly recommend
13. PERINATAL FACTORS
Increasing evidence links prenatal exposures to adverse health outcomes. Perinatal risk reduction is an area in which
pediatric care providers can potentially
be effective, because they are often the
only physicians whom a mother sees between pregnancies. The expert panel
identified 3 potential areas for consideration: maternal obesity; choice of neonatal feeding method; and maternal smoking cessation. Maternal obesity is
associated with gestational DM, higher
birth weight, childhood obesity measured by increased BMI, and increased
risk of the metabolic syndrome and
evidence supports a benefit for interventions directed at maternal
smoking cessation during pregnancy
(grade A). Weaker evidence suggests
that these interventions do not prevent relapse after delivery. Trials of
cessation in the postpartum period,
which would be the most applicable to
pediatric providers, have been limited
in number and suggest that for maternal smoking cessation to be sustained, specific continued support in
the pediatric care setting is required.
have resulted in any reported adverse effects related to the interventions (no grade).
● The expert panel believes that pediat-
Grades reflect the findings of the evidence review; recommendation levels reflect the consensus opinion of the expert
panel; and supportive actions represent expert consensus suggestions from the expert panel provided to support
implementation of the recommendations (they are not graded).
dren with multiple cardiovascular risk
factors.
● The expert panel found that strong
● No smoking-cessation interventions
NHANES indicates National Health and Nutrition Examination Survey; ADA, American Diabetes Association.
Smoking-cessation guidance during pregnancy is strongly advised
Supportive action:
Pediatric care providers should be provided with appropriate
training and materials to deliver, or refer to, a smokingcessation program in the postpartum period for all smoking
women of childbearing age
This intervention should be directly linked to ongoing smokefree home recommendations directed at all young mothers and
fathers as described in the “Tobacco Exposure” section
Conclusions and Grading of the
Evidence Review on Maternal
Smoking Cessation
T2DM in offspring. However, the expert
panel could not identify any prepregnancy or postpartum studies that addressed maternal obesity in a pediatric
care setting, and more general approaches to preventing or treating obesity in women of reproductive age are
beyond the scope of this report. A detailed discussion of childhood obesity itself is the subject of “Overweight and
Obesity.” With regard to choice of neonatal feeding method, the cardiovascular
advantages of breastfeeding as the primary source of nutrition for infants are
emphasized in “Nutrition and Diet.”
Therefore, the evidence review for this
section is focused on maternal smoking
cessation.
ric care providers can play a role in
helping mothers to remain smokefree or to quit smoking in the interpregnancy interval. For most women,
this interval will extend to the early
first trimester of any subsequent
pregnancy. The pediatric well-child
schedule calls for ⬃10 visits in the
first 2 years of life, and mothers attend most of those visits, so the pediatric care provider usually sees
women in this period more than any
other health care professional. Pediatric care providers often have a sustained relationship with the mother
and her infant, and many already advocate for parental smoking cessation in their efforts to promote a
smoke-free environment for children. Pediatric providers and/or
their staff need to be trained to either deliver or refer to a long-term
maternal smoking-cessation program (no grade).
Recommendations for maternal smoking cessation are listed in Table 13-1.
PEDIATRICS Volume 128, Supplement 5, December 2011
S255
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(Continued from first page)
Associates for the State of Ohio, Bureau of Early Intervention Services and Help Me Grow program, and has received funding/grant support for research from the
NIH; Dr Kwiterovich has served as a consultant or advisory board member for Merck, Schering-Plough, Pfizer, Sankyo, LipoScience, and Astra Zeneca, has served
on speaker’s bureaus for Merck, Schering-Plough, Pfizer, Sankyo, Kos, and Astra Zeneca, and has received funding/grant support for research from Pfizer,
Merck, GlaxoSmithKline, Sankyo, and Schering-Plough; Dr McBride has served as a consultant or advisory board member for Bristol-Myers Squibb and Merck
and has served on speaker’s bureaus for Kos, Merck, and Pfizer but declares no relevant relationships since July 2007; Dr McCrindle has been a consultant for
Abbott, Bristol-Myers Squibb, Daichii Sankyo, and Roche, owns stock in CellAegis and reports funding/grant support for research from Astra Zeneca, Sankyo,
Merck, Schering-Plough, and the NIH; Dr Urbina reports funding/grant support for research from Merck, Schering-Plough, Sankyo, and the NIH; and Dr VanHorn
has provided advice to Chartwells School Food Service and has received funding/grant support for research from General Mills and the NIH. Drs Benuck,
Christakis, Dennison, O’Donnell, Rocchini, and Washington have indicated they have no financial relationships relevant to this article to disclose.
Funded by the National Institutes of Health (NIH).
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